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DIETETICS  FOR  NURSES 


THE  MACMILLAN  COMPANY 

NEW  YORK   •    BOSTON   •    CHICAGO  •    DALLAS 
ATLANTA  •    SAN    FRANCISCO 

MACMILLAN  &  CO.,  Limited 

LONDON  •    BOMBAY  •    CALCUTTA 
MELBOURNE 

THE  MACMILLAN  CO.  OF  CANADA,  Ltd. 

TORONTO 


DIETETICS  FOR  NURSES 


BY 

FAIRFAX   T.   PROUDFIT 

FORMER    INSTRUCTOR   IN    DIETETICS   IN 

JHE   LUCY   BRINKLEY    HOSPITAL 

AND    BAPTIST    MEMORIAL 

HOSPITAL,  MEMPHIS 

TENNESSEE 


Nefo  gorfe 

THE    MACMILLAN    COMPANY 
1918 


All  rights  reserved 


■ps 

Biouxnr 

LmpARr 


COPYBIGHT,   1918, 

By  the  MACMILLAN  COMPANY. 
Set  up  and  electrotyi>ed.    Published  November,  1918. 


Nortooot)  i^ress 

J.  8.  Gushing  Co.  —  Berwick  «fe  Smith  Co. 

Norwood,  Mass.,  U.S.A. 


Dedicated 

to  tbe 

<5reat  armis  of  IRurses 

in  tbe  Service 


384Sii9 


The  author  wishes   to  acknowledge  her 

APPRECIATION  FOR  THE  COURTESY  EXTENDED 
TO  HER  BY  MANY  MEMBERS  OF  THE  MEDICAL 
PROFESSION,    MOST    ESPECIALLY    TO    DrS.    WaR- 

REN  Coleman,  Louis  Leroy,  Otis  Warr,  and 
Pearl  Stevens  for  valuable  suggestions 
AND  TO  Dr.  F.  S.  Safford  for  assistance 
in  the  preparation  of  the  manuscript 


PREFACE 

No  other  science  has  so  much  to  do  with  the  general  welfare  of 
mankind  as  the  study  of  food  and  its  effects  in  the  human  body. 
When  we  use  the  term  "dietetics"  as  representing  "the  effect  of 
the  food  in  the  human  body,"  we  do  so  in  a  very  broad  sense,  for 
the  subject  is  a  big  one,  requiring  comprehensive  terms  to  ex- 
press it. 

The  problems  of  nutrition  are  many.  Food  alone  is  no  small 
subject  and  a  still  greater  one  is  the  utilization  of  food  materials 
in  such  a  way  that  the  body  may  gain  the  greatest  value  with  the 
least  expenditure  of  vital  forces.  These  problems  are  discussed 
in  this  text  and  the  methods  of  overcoming  them  are  given  in  the 
simplest  possible  language.  For  this  purpose  the  subject  of 
nutrition  has  been  divided  into  groups:  (1)  a  comprehensive 
study  of  the  sources  of  food,  its  composition  and  nutritive  value ; 
(2)  the  effect  of  food  in  the  body  under  normal  conditions,  as  in 
health;  and  (3)  its  behavior  and  effect  when  conditions  in  the 
body  become  abnormal,  as  in  disease.  In  this  way  much  of  the 
non-essential  material  is  eliminated  from  the  course  of  study  and 
only  that  included  which  it  is  necessary  for  the  nurse  to  under- 
stand and  which  she  will  constantly  use  both  in  the  hospital  and 
later  on  in  the  practice  of  her  profession.  The  simple  methods  of 
study  presented  in  this  text  are  given  with  the  idea  of  avoiding 
confusion  in  the  mind  of  the  average  pupil  nurse  by  fitting  in  the 
course  with  her  other  studies  rather  than  by  making  it  stand  out 
as  a  separate  subject.  In  this  way  she  will  be  able  to  see  at  a 
glance  the  connection  between  the  body  processes  and  the  ma- 
terials which  are  used  to  carry  them  on.  Thus  her  study  of 
physiology,  anatomy  and  bacteriology  go  hand  in  hand  with  that 
of  dietetics,  each  bearing  a  distinct  relationship  to  the  others. 

ix 


TABLE  OF  CONTENTS 

Chap.  Paqb 

I.    Food       . 1 

II.    The  Selection,  Care,  and  Adulteration  of  Food  .        .  28 

III.  The  Fuel  Value  of  Food 46 

IV.  Special  Diets,  Metric  System,  Percentage  Calculation, 

AND  Thermometry 58 

V.    Formulas  for  the  Preparation  of  Food  for  the  Sick  63 

VI.    The  Human  Body 107 

VII.    The  Food  Requirements  of  the  Body      ....  131 

VIII.    Methods  of  Feeding  in  Normal  and  Abnormal  Conditions  140 

IX.    Pregnancy  and  Lactation 159 

X.    Infant  Feeding 166 

XI.    Care  and  Feeding  of  Infants  and  Children  in  Abnormal 

Conditions 191 

XII.    Feeding  in  Infectious  Diseases  of  Infancy  and  Child- 
hood      209 

XIII.  The   Feeding  of  Adults  in  Diseases  of  the   Gastro- 

intestinal Tract 226 

XIV.  Diseases  of  the  Intestinal  Tract 243 

XV.    Typhoid  Fever       .        .        .        .   *     .        .        .        .        .261 

XVI.    Fevers  in  General 273 

XVII.    Diseases  of  the  Respiratory  Tract          ....  279 

XVIII.    Dietetic  Treatment  Before  and  After  Operation         .  289 

XIX.    Urinalysis 298 

XX.    Acute  and  Chronic  Nephritis 305 

XXI.    Diseases  of  the  Heart 331 

XXII.    Diabetes  Mellitus 337 

XXIII.  Diseases  of  the  Liver 379 

XXIV.  Gout,  Obesity,  Emaciation 391 

XXV.    Other  Conditions  More  or  Less  Affected  by  Diet  .        .  421 

xi 


SECTION  I 
FOOD  AND  ITS  SIGNIFICANCE 

Lbctube  and  Laboratobt  Dietetics  for  the  Probationer 


CHAPTER  I 

FOOD 

Food  Materials.  —  Food  is  the  name  given  to  any  substance 
which,  taken  into  the  body,  is  capable  of  performing  one  or  more 
of  the  following  functions  : 

1.  Building  and  repairing  tissue,  maintenance,  growth,  and 
development  of  the  muscles,  bones,  nerves,  and  the  blood. 

2.  Furnishing  the  energy  for  the  internal  and  external  work  of 
the  body. 

3.  Regulating  the  body  processes,  maintaining  the  proper 
alkalinity  and  acidity  of  the  various  fluids  throughout  the  body, 
regulating  the  proper  degree  of  temperature,  and  determining  the 
osmotic  pressure,  etc. 

For  the  convenience  of  study  scientists  have  arranged  the  food- 
stuffs in  groups : 

1.  According  to  type ; 

2.  According  to  their  chemical  composition ; 

3.  According  to  the  function  they  perform  in  the  body. 

All  foods  are  composed  of  certain  chemical  elements ;  namely, 
carbon,  oxygen,  hydrogen,  nitrogen,  sulphur,  phosphorus,  iron, 
magnesium,  potassium,  chlorine,  sodium,  calcium,  with  traces  of 
various  others.  The  manner  in  which  these  elements  are  com- 
bined and  the  amounts  in  which  they  occur  determine  the  group 
to  which  the  combination  belongs,  and  give  to  the  foodstuff  its 
characteristic  position  in  human  nutrition. 
B  1 


2         ^i^-^J^r^.^lryiETETIGS  FOR  NURSES 

One  combination  cannot  be  said  to  be  of  greater  importance 
than  another,  since  the  needs  of  nature  are  best  met  by  a  judicious 
combination  of  all,  but  the  wear  and  tear  of  life  can  be  more  effi- 
ciently accounted  for,  and  the  strain  of  the  organism  reduced  to 
a  minimum,  if  the  chemical  combinations  are  furnished  in  the 
amounts  which  science  has  proved  to  be  necessary  to  keep  the 
body  in  good  order. 

The  following  table  gives  a  definite  idea  as  to  the  classification 
of  the  foodstuffs  according  to  their  chemical  composition  and 
their  functional  activity  in  the  body : 


TABLE  I 

Classification  of  Food  Materials 


Fuel 
Foods 


Tissue 
Builders 


Regulators 
of  Body 
Processes 


Proteins 


f  Carbon 

Oxygen 

Hydrogen 

Nitrogen 

Organic      J  [  Carbon 

group     ]  Carbohydrates  i  Hydrogen  "  " 

[ Oxygen 
r  Carbon 
\  Hydrogen 
[ Oxygen 

Inorganic  j  water,  H.0      {^^ir 

group  M  Tvyr.        1      1.      j  Comprised  of  the  remaining  chemical  ele- 
[  Mineral  salts     |      nients 


Fats 


SOURCES  OF  FOODSTUFFS 

The  foods  commonly  used  in  human  nutrition  are  drawn  from 
various  sources  of  both  animal  and  plant  life,  as  may  be  seen  in 
Table  II.  The  three  substances  belonging  to  the  organic  group 
of  foodstuffs  are  all  utilized  by  the  body  as  fuel.  The  chief  source 
of  body  fuel,  however,  may  be  said  to  be  plant  life.  From  sugar- 
cane and  sugar  beets  a  pure  form  of  carbohydrate  is  obtained. 

^  The  chemical  elements  as  combined  in  the  inorganic  group  do  not  furnish 
energy  or  build  tissue,  but  since  they  enter  into  and  assist  the  organic  group  in 
every  function  which  they  perform  they  are  classed  with  that  group  as  food. 


FOOD  3 

This  cane  sugar  (sucrose)  is  found  to  a  less  extent  in  the  juices 
of  the  sweet  fruits  and  vegetables,  such  as  oranges,  grapes,  apples, 
plums,  corn,  peas,  etc.  This  is  the  form  in  which  the  carbohydrate 
circulates  through  plants.  Starch,  another  form  of  pure  carbo- 
hydrate, is  the  form  in  which  that  foodstuff  is  stored  in  plants. 
It  is  found  widely  distributed  in  cereal  grains,  rice,  potatoes 
and  other  tubers,  such  as  taro,  which  resembles  the  yam  of  the 
southern  part  of  the  United  States,  and  tapioca  from  the  manioc 
root.  Bananas,  dried  beans,  peas,  and  chestnuts  also  contain 
starch,  although  not  in  such  quantities  as  in  the  just-mentioned 
foods. 

The  fats,  coming  next  to  the  carbohydrates  as  a  source  of  body 
fuel,  are  obtained  from  olives,  cotton  seed,  peanuts,  almonds 
and  other  nuts,  and  cocoa  beans.  The  amount  of  fat  in  other 
vegetables  is  very  small. 

The  proteins  found  in  vegetables,  grains,  and  nuts  are  distributed 
in  varying  amounts.  The  legumes — beans,  peas,  lentils,  and  pea- 
nuts —  contain  the  largest  amount,  the  cereal  grains  the  next  larg- 
est, and  the  nuts,  such  as  almonds,  pecans,  walnuts,  and  filberts, 
still  less.  Other  plants  contribute  a  small  amount  of  protein, 
but  not  enough  to  be  greatly  considered.  Within  the  animal 
organism  plants  are  made  over  into  body  protein  and  utilized  as 
such  in  the  food  of  man. 

The  fats  and  proteins  belonging  to  animal  life  are  in  more 
concentrated  form  than  those  found  in  plants.  The  muscular 
tissue  is  made  up  of  several  kinds  of  protein,  such  as  albumens, 
globulins,  etc. ;  the  glandular  organs  of  other  types,  such  as 
nucleoproteins ;  while  the  blood  is  made  up  of  soluble  albumens, 
hemoglobins,  globulins,  etc.  Milk  contains  a  still  different  type 
of  protein,  known  as  casein,  and  eggs  contain  both  pure  albumens 
(the  white  part)  and  vitellin  (the  yolk).  The  brain  contains 
phosphoprotein,  a  simple  protein  with  some  undefined  phos- 
phorus-containing substance,  and  lecithoproteins,  compounds  of 
the  protein  molecule  with  lecithins. 

Since  protein  is  such  a  very  important  substance,  being,  as  it  is, 
the  only  foodstuff  capable  of  building  and  repairing  tissue,  it  is 


4 


DIETETICS  FOR  NURSES 


well  for  the  nurse  to  recognize  the  more  important  proteins  and  to 
know  from  what  source  they  are  derived.  The  following  table 
shows  some  of  the  more  important  ones  : 


TABLE   112 

Vegetable 
Proteins 

Source 

Animal 
Proteins 

Source 

GUadin* 

Wheat 

Casein* 

Cow's  milk 

Rye 

Lactalbumen* 

Cow's  milk 

Cotton  seed 

Myosin* 

Lean  meat 

Globulin* 

Squash  seed 

Ovovitellin* 

Egg  yolk 

Wheat 

Albumen* 

Egg  white 

Glutelin* 

Maize 

Hemoglobin* 

Zein 

Maize 

Gelatin 

Bones 

Glycinin 

Soy  bean 

Connective  tissue 

Excelsin* 

Brazil  nut 

tendons 

Edestin* 

Hemp  seed 

Collagen 

Hordein 

Barley 

Legumen 

Beans 
Peas 
Lentils 
Peanuts 

It  must  be  understood  that  most  of  our  food  materials  are  made 
up  of  more  than  one  of  the  foodstuffs.  Beef,  for  example,  con- 
tains bones  (refuse),  water,  protein,  fat,  and  ash.  The  following 
table  shows  the  percentage  composition  of  100  pounds  of  beef. 


TABLE   III 

Composition  of  Beef 


Refuse 
Per  Cent 

Water 
Per  Cent 

Protein 
Per  Cent 

Fat 
Per  Cent 

Ash 
Per  Cent 

16.0 

53.0 

15.4 

15.0 

0.6 

2  The  proteins  marked  with  a  star  are  capable  of  producing  growth,  while  those 
without  must  have  growth-producing  substances  added,  because  alone  they  can 
merely  maintain  the  body.  According  to  Mendel,  animals  nourished  on  these  defi- 
cient proteins  "for  over  long  periods  exhibit  an  interesting  type  of  stunted  condition 
resembling  properly  nourished  younger  animals  which  have  obtained  the  same  body 
weight."  Fortunately,  however,  the  animals  dwarfed  in  this  way  from  insuflScient 
proteins  have  not  lost  the  power  to  grow. 


FOOD 


Composition  of  Beef 


Refuse 

Edible  Portion 

Per  Cent 

Water 
Per  Cent 

Protein 
Per  Cent 

Fat 
Per  Cent 

Ash 
Per  Cent 

16.0 

62.9 

18.3 

17.9 

0.7 

In  interpreting  the  above  tables  it  is  important  to  note  the 
form  in  which  the  data  are  given.  "  In  the  above  examples,  since 
the  beef  contains  16  per  cent  refuse  and  84  per  cent  moist  edible 
material,  the  percentage  of  protein  or  fat  in  the  material  as  pur- 
chased divided  by  0.84  gives  the  percentage  in  the  edible  portions.; 
and  the  percentage  in  the  edible  portion  multiplied  by  0.84  gives 
the  percentage  in  the  material  as  purchased."  ^ 

The  following  table  shows  where  the  foodstuffs  are  found.  This 
is  given  to  facilitate  the  formulation  of  a  diet.  A  table  containing 
the  chemical  composition  of  the  food  materials  will  be  found 
at  the  end  of  this  section. 

TABLE  IV 

Showing  the  Chemical  Combinations,  and  the  Sources  prom 
WHICH  They  are  Drawn 


Proteins 


Milk,  cheese  (especially  skim-milk  cheeses). 

Eggs. 

Meat  (lean  meat  in  particular). 

Poultry,  game. 

Fish. 

Cereals,  corn,  wheat,  rye,  oats,  etc. 

Bread  and   breadstuffs    (crackers,  pastry,   macaroni, 

cake). 
Beans,  peas,  lentils. 
Cotton  seed. 
Nuts. 
Gelatine. 


3  The  above  tables  and  explanation  are  quoted  from  "Chemistry  of  Food  and 
Nutrition,"  by  Henry  Sherman. 


DIETETICS  FOR  NURSES 


Carbohydrates 


Fats 


Wheat  products  (bread,  cake,  crackers,  pastry,  maca- 
roni, spaghetti). 

Cereal  grains,  breakfast  foods. 

Corn  products,  corn  meal,  green  corn. 

Rice,  sago,  tapioca,  taro. 

Potatoes  (white  and  sweet). 

Starchy  fruits  (bananas). 

Sweet  fruits  (oranges,  grapes,  pineapples). 

Dried  fruits  (prunes,  dates,  raisins,  currants). 

Sugar  cane,  sorghum  cane. 

Sugar  beets,  sugar  maples. 

Products  made  from  sugar  (candy, 'jellies,  preserves, 
marmalade). 

'  Butter,  cream,  cheese. 

Olive  oil,  cotton  seed  oil,  peanut  oil,  corn  oil,  almond 
oil. 

Soy  bean. 

Corn  meal,  cotton  seed  meal  and  flour,  oatmeal. 

Pork  (bacon  especially),  other  fat  meat. 

Codfish  (and  other  fatty  fish). 

Eggs  (yolk). 

Cocoanut,  chocolate. 
.  Brazil  nuts,  almonds,  pecans,  and  other  nuts  rich  in  fat. 


Water 


•1 


Mineral  salts 
(organic  form) 


All  foodstuffs  except  those  which  have  been  put  through 
a  drying  process. 

Nitrogen  (in  proteins,  meat,  eggs,  milk,  fish,  gluten 

of  wheat,  zein  of  corn  meal,  legumen  of  beans,  peas, 

and  lentils). 
Phosphorus  (eggs,  yolk  especially,  cream,  vegetables, 

whole  wheat,    cereals,    breadstuffs,  oatmeal,   dried 

beans  and  peas). 


Iron  (organic  and  f  ■^^^^'  ^lilk,  lean  meat,  cereal  products,  whole  wheat, 
inorganic  form)  i      dried  beans  and  peas,  vegetables,  spinach  in  particu- 
[      lar,  onions,  mushrooms,  fruits,  port  wine. 

Milk.4 
Eggs. 
Soft  tissues  and  fluids  of  all  animals,  skeleton  and 

teeth  of  animals. 
Wheat  (the  entire  grain),  flour,  oatmeal,  polished  rice. 
Dried  beans  and  peas. 
Green  vegetables    (beets,   carrots,   parsnips,   turnips, 

potatoes). 
Fruits    (apples,   bananas,   oranges,   pineapples,   dried 

prunes). 
Nuts  (almonds,  peanuts,  walnuts). 

*  One  quart  of  milk  contains  more  calcium  than  a  quart  of  clear  saturated 
solution  of  lime  water. 


Calcium  (organic 
and  inorganic 
form) 


FOOD 


Sulphur  (organic 
and  inorganic 
form) 


Sodium,      potas 
sium,     magne-  ^ 
sium,      iodine 
chlorine 


The  proteins 


'  Lean  beef,  eggs,  milk. 
Wheat  flour,  entire  wheat,  crackers,  etc. 
Oatmeal. 
Beans,  peas. 
Potatoes. 


'  These  elements  are  associated  with  the  other  mineral 
salts  in  foods,  and  a  diet  in  which  they  are  adequately 
suppUed  furnishes  sufficient  magnesium,  potassium, 
chlorine,  sodium,  and  iodine  for  the  general  needs  of 
the  body. 


SOURCES   AND    CHEMICAL   COMPOSITION   OF   FOOD 

Before  it  is  possible  to  understand  the  effect  of  food  in  the 
body,  it  is  necessary  to  understand  the  chemical  combinations 
themselves.  The  outline  just  given  shows  the  grouping  of  these 
combinations,  but  a  brief  description  of  each  will  be  found  essential 
to  insure  an  intelligent  study  of  the  subject. 

Organic  Foodstuffs:  Carbohydrates,  Fats,  and  Proteins 

"  The  carbohydrates  include  the  simple  sugars  and  all  those 
more  complex  substances  (such  as  dextrin,  starch,  etc.)  which  by 
hydrolysis  can  be  resolved  into  simple  sugar."  ^ 

There  are  nine  carbohydrates  which  are  of  particular  interest, 
since  they  are  most  important  in  human  food  and  nutrition. 
These  are  grouped  as  follows : 


Monosaccharides 
C6H12O6 

Disaccharides , 
C12H22O11 

Polysaccharides , 
CeHioOs 


'  Glucose. 

Fructose. 

Galactose. 

Sucrose. 

Maltose. 
I  Lactose. 

Starch. 

Dextrin. 

Glj'^cogen. 

Cellulose. 


The  monosaccharides,  always  containing  six  carbon  atoms,  are 
very  soluble  and  digestible.  Of  these  simple  sugars,  glucose  will 
be  found  widely  distributed  throughout  plant  life,  and  to  a  less 
extent  in  that  of  animals,  where  it  forms  an  essential  part  of  the 

'  Quoted  from  "Chemistry  of  Food  and  Nutrition,"  by  Henry  C.  Sherman. 


8  DIETETICS  FOR  NURSES 

blood  (0.1%).  It  is  abundant  in  grapes,  constituting  more  than 
half  the  solid  matter.  Onions,  sweet  corn,  and  unripe  potatoes 
also  contain  appreciable  amounts  of  this  sugar.  Glucose  may  be 
obtained  by  hydrolysis  of  many  carbohydrates,  either  with  enzymes 
or  acids. 

Fructose  is  more  or  less  associated  with  glucose  in  fruits  and 
plant  juices  and  is  particularly  abundant  in  honey,  constituting 
about  half  of  the  solids  of  that  substance. 

Galactose,  unlike  the  other  two  sugars  belonging  to  the  mono- 
saccharides, is  not  found  free  in  nature,  but  is  the  result  of 
enzymic  action  upon  milk  sugar.  A  like  result  is  obtained  by  the 
hydrolysis  of  milk  sugar  by  acids.  The  monosaccharides  are 
susceptible  to  alcoholic  fermentation  and  have  a  common  function 
of  producing  glycogen  in  the  body  and  hence  being  utilized  by  the 
body  for  the  maintenance  of  the  normal  glucose  content  of  the 
blood. 

The  disaccharides  with  which  we  are  most  familiar  and  with 
which  we  are  chiefly  concerned  in  food  and  nutrition  are  sucrose, 
lactose,  and  maltose.  These  three  sugars  are  found  widely  dis- 
tributed in  nature,  being  abundant  in  the  sweet  fruits  and  also  in 
many  vegetables.  Sucrose,  or  cane  sugar,  is  found  in  the  sugar 
and  sorghum  canes,  in  sugar  beets,  sugar  maples,  sugar  palms, 
also  in  carrots,  sweet  potatoes,  and  other  vegetables,  and  in 
pineapples  and  other  fruits.  This  sugar  is  readily  hydrolyzed  by 
acids  or  by  the  inverting  enzyme  sucrase  in  the  intestinal  juice, 
the  end  product  being  fructose  and  glucose.  Lactose,  or  milk 
sugar,  occurs  in  the  milk  of  all  mammals;  the  end  products 
resulting  from  the  hydrolysis  of  this  sugar  by  either  acids  or  lactase, 
the  hydrolytic  enzyme  in  the  intestinal  juice,  are  glucose  and 
galactose.  Maltose,  or  malt  sugar,  is  produced  by  the  diastatic 
action  of  certain  enzymes  upon  starch.  It  is  formed  during  the 
germinating  process  of  cereal  and  malt  products.  It  is  also 
formed  during  the  process  of  digestion  by  the  action  of  the  salivary 
enzyme  ptyalin  and  the  pancreatic  enzyme  amylopsin  upon  the 
starch  in  food. 

The  polysaccharides  are  complex  in  character,  being  built  up  of 


FOOD  9 

many  sugar  molecules,  and  upon  digestion  must  be  broken  down 
into  the  simple  sugars  before  they  can  be  utilized  by  the  body. 
Starch  is  the  form  in  which  the  plant  stores  her  supply  of  carbo- 
hydrates. It  will  be  found  in  this  form  in  roots  and  (mature) 
tubers,  three-fourths  of  the  bulk  of  which  is  made  up  of  this 
material.  From  one-half  to  three-quarters  of  the  solids  of  grains 
is  made  up  of  starch  also.  Pure  starch  is  a  fine  white  powder, 
odorless  and  almost  tasteless.  It  is  insoluble  in  cold  water  and 
alcohol,  but  changes  from  an  insoluble  substance  to  a  more 
soluble  one  upon  the  application  of  heat,  dextrin.  In  warm  water, 
starch  granules  swell  as  they  absorb  the  water ;  and  finally,  with  a 
continuation  of  the  heat,  the  starch  passes  into  a  gelatinous  form, 
or  starch  paste.  Upon  hydrolysis  starch  gives  first  a  mixture  of 
dextrin  and  maltose,  then  glucose  alone  as  the  end  product.  This 
hydrolysis  may  be  the  result  of  enzymic  action,  as  occurs  upon 
bringing  starch  in  contact  with  the  ptyalin  in  the  saliva,  or  with 
the  amyloptic  enzyme  in  the  pancreatic  juice ;  or  it  may  be  the 
result  of  boiling  starch  w^ith  acid,  as  is  seen  in  the  manufacture  of 
commercial  glucose.  Dextrin,  as  has  already  been  stated,  is  an 
intermediate  product  of  the  hydrolysis  of  starch  by  acid,  or  enzymes 
of  digestion.  Glycogen  is  the  form  in  which  carbohydrates  are 
stored  in  the  body,  just  as  starch  is  the  form  in  which  they  are 
stored  in  plants.  It  is  found  in  all  parts  of  the  body,  but  is  espe- 
cially abundant  in  the  liver.  Here  it  is  stored  in  the  cell  substance 
rather  than  in  the  nucleus.  The  storage  of  glycogen  in  the  human 
body  depends  largely  upon  the  mode  of  life  and  upon  the  diet. 
Active  muscular  work,  especially  out  of  doors,  uses  up  the  stored 
glycogen  with  great  rapidity,  while  rest  and  a  sedentary  life 
promote  its  storage.  The  body  readily  converts  its  supply  of 
glycogen  into  glucose,  the  form  in  which  the  body  uses  the  carbo- 
hydrates for  fuel.  Cellulose  is  a  woody,  fibrous  material  insoluble 
In  water  and  to  a  certain  extent  impervious  to  the  action  of  the 
digestive  enzymes.  This  carbohydrate  constitutes  the  skeleton 
of  plants  just  as  the  bones  constitute  that  of  the  animal  body. 
Formerly  it  was  believed  that  the  cellulose  in  food  was  a  waste 
product  in  the  body,  more  or  less  useful  on  account  of  the  bulk 


10  DIETETICS  FOR  NURSES 

which  it  lent  to  the  food  mass  in  the  intestines  but  wholly  useless 
as  a  food.  Recent  experiments,  however,  have  proved  this 
theory  more  or  less  incorrect,  since  much  of  the  cellulose  eaten  is 
broken  down  and  converted  into  glucose  and  utilized  by  the  body 
for  the  production  of  energy  in  the  same  way  that  any  other 
carbohydrate  is  used.  However,  it  is  doubtless  true  that  this 
food  material  requires  a  longer  time  for  digestion,  and  much  of  it 
escapes  oxidation  entirely.  Hence  it  passes  down  the  alimentary 
canal  into  the  feces,  thus  promoting  peristalsis  along  the  entire 
tract. 

FATS 

The  fats  are  derived  from  both  animal  and  vegetable  life,  and, 
like  the  carbohydrates,  are  utilized  by  the  body  for  the  production 
of  energy  and  its  by-product,  heat.  They  are  the  most  concen- 
trated of  the  fuel  foods,  and  again,  like  the  carbohydrates,  are 
composed  of  combinations  of  carbon,  hydrogen,  and  oxygen.  The 
oxygen  atoms  in  this  group,  however,  occur  in  much  smaller 
numbers  than  in  the  sugars  and  starches.  The  chemical  structure 
of  the  fats  shows  that  no  matter  how  many  hydrogen  and  carbon 
atoms  a  particular  fat  may  contain,  there  will  never  be  more  or  less 
than  two  oxygen  atoms.  This  constancy  of  the  oxygen  atoms 
furnishes  the  chief  characteristic  of  this  organic  food  compound. 
The  fats  are  defined  as  combinations  of  fatty  acids  and  glycerin ; 
that  is,  when  a  fat  is  brought  into  contact  with  either  the  lipases  of 
digestion,  or  with  strong  reagents,  it  breaks  down  into  these  two 
constituents.  No  two  fats  are  alike ;  they  may  contain  practically 
the  same  fatty  acids,  but  they  will  be  in  different  proportions. 
Hence  it  is  believed  that  it  is  to  these  substances  that  each  fat 
owes  its  characteristic  individuality.  It  is  believed  that  fats 
owe  their  flavor,  odor,  and  color  to  substances  which  occur  in 
minute  quantities  with  the  fatty  acids  and  that  if  the  fats  were 
sufficiently  refined  they  would  be,  with  the  exception  of  butter, 
odorless,  tasteless,  and  colorless. 

T3rpes  of  Fatty  Acids.  —  The  fatty  acids  with  which  we  are 
particularly  concerned  in  nutrition  are :    Butyric  Acid,  Palmitic 


FOOD  11 

Acid,  Stearic  Acid,  and  Oleic  Acid,  but  there  are  many  others  which 
occur  in  combination  with  those  just  mentioned.  Butyric  acid 
is  the  substance  from  which  butter  derives  its  name  and  flavor. 
It  is  the  characteristic  fatty  acid  of  butter  fat,  forming  from  five 
to  six  per  cent  of  the  fatty  acids  of  that  substance.  Butyric 
acid  is  found  also  in  very  small  quantities  in  several  other  fats. 
Stearic  acid  (stearin)  is  found  in  most  fats,  and  is  especially 
abundant  in  the  more  solid  varieties  and  those  having  a  high 
melting  point,  such  as  beef  tallow  and  suet.  In  fact,  it  is  to  this 
fatty  acid  that  these  fats  owe  their  solidity.  Butter  contains 
stearic  acid,  but  since  there  are  also  several  other  fatty  acids 
present  it  does  not  have  the  solidity  of  tallow  or  suet.  Many  of 
the  compound  butter  mixtures  or  butter  substitutes  are  combina- 
tions of  fats  high  in  stearin  and  those  of  oily  nature,  the  stearin 
being  added  to  give  solidity  to  the  mixture.  Palmitic  acid  is  also 
classed  among  the  more  solid  fats  and  occurs  abundantly  in  the 
fats  of  both  animal  and  vegetable  origin,  including  many  of  the 
fatty  oils  and  waxes,  such  as  spermaceti  and  beeswax.  Oleic 
acid  (olein)  is  found  in  most  of  the  fats  and  fatty  oils.  It  is  one 
of  the  most  important  of  the  fatty  acids,  constituting  as  it  does 
the  greater  part  of  the  typical  oils,  such  as  olive  oil,  cottonseed  oil, 
and  lard. 

Phosphorized  Fats:  Lecithins,  lecithans,  etc.,  occur  in  large 
quantities  in  the  brain  and  nerve  tissues,  and  to  a  less  extent  in 
other  tissues.  Egg  yolk  is  the  food  material  conspicuous  for  its 
high  percentage  of  phosphorized  fat.' 

Volatile  Qil.  —  These  substances  are  not  to  be  classed  as  true 
fat ',  having  little  in  common  with  those  substances.  A  few  of  the 
volatile  oils,  such  as  oil  of  bergamot  from  orange  peel,  and  oil  of 
lemon  from  lemon  peel,  are  used  as  flavoring  agents. 

Sources  of  Fat.  —  The  chief  sources  of  fat  in  nutrition  are  milk 
and  milk  products,  such  as  butter,  cream,  and  cheese;  meats, 
such  as  pork  (bacon,  lard,  salt  pork)  and  other  fat  meats;  and 
fatty  fish,  such  as  codfish ;  beef,  beef  suet,  and  tallow ;  mutton 
tallow  and  suet ;  oily  nuts,  such  as  almonds,  peanuts,  pecans, 
etc. ;  and  certain  seed,  such  as  cotton  seed,  olives,  corn,  etc. 


12  DIETETICS  FOR  NURSES 

Physical  Peculiarities  of  Fats.  —  It  may  not  come  amiss  to 
understand  some  of  the  physical  peculiarities  of  this  class  of  food 
materials ;  hence  a  brief  account  of  a  few  of  these  is  included  here. 
All  true  fats  will  soak  readily  into  many  materials,  causing  what 
is  known  as  a  grease  spot.  A  drop  of  oil  or  other  fat  upon  a  piece 
of  paper  leaves  a  translucent  spot  which  does  not  evaporate  upon 
standing.  This  is  the  simplest  test  for  true  fats.  Volatile  fats 
leave  only  a  temporary  grease  spot  which  evaporates  eventually. 
Fats  are  not  soluble  in  water,  but  are  so  in  ether  and  to  a  certain 
extent  in  alcohol. 

Emulsions  are  conipounds  of  a  fluid  and  a  fat.  The  fat  in  these 
substances  is  not  dissolved,  but  is  held  in  suspension  by  reason  of 
the  microscopic  division  of  the  fat  globules.  Such  mixtures  are 
opaque  in  character.  Milk  is  the  best  known  of  the  natural 
emulsions.  In  order  for  emulsion  to  be  formed  it  is  necessary  that 
there  be  present  in  the  solution  some  substance  other  than  the  fat 
which  will  coat  the  surface  of  the  fat  globule  and  prevent  it  from 
mingling  with  other  globules.  This  substance  is  sometimes  a 
protein,  as  in  milk. 

Cleansing  fluids,  such  as  benzine,  gasoline,  naphtha,  chloroform, 
etc.,  owe  their  cleansing  properties  entirely  to  their  ability  to 
dissolve  fats.  ^ 

PROTEINS 

All  foods  which  are  capable  of  supplying  the  body  with  fuel  are 
composed  of  combinations  •  of  carbon,  hydrogen,  and  oxygen. 
Science  has  proved  that  the  most  efficient  of  fuel  foods  are  those 
classed  as  carbohydrates  and  fats.  However,  it  must  be  kept  in 
mind  that  there  are  other  needs  just  as  vital  as  that  of  the  pro- 
duction of  energy,  namely,  that  of  building  and  repairing  the 
tissues. 

The  wear  and  tear  of  the  body  is  continuous,  hence  it  is  clearly 
seen  that  unless  some  substance  is  supplied  to  make  good  these 
losses  life  will  inevitably  cease.  The  only  element  which  is  known 
to  have  this  property  is  nitrogen,  and  the  proteins  have  the  entire 
monopoly  of  this  element  for  the  body.     Other  substances,  both 


FOOD  13 

organic  and  inorganic  in  form,  such  as  the  essential  oils, 
nitrogenous  fats  and  alkaloids,  as  well  as  the  nitrogenous 
extractives,  ammonium  salts  and  nitrates,  represent  a  certain 
percentage  of  nitrogen  in  the  body,  but  it  is  to  the  proteins  that 
the  tissue  building  and  repairing  is  relegated.  Protein  is  the  name 
given  to  a  number  of  simple  substances  all  containing  nitrogen. 
These  substances  are  known  as  amino  acids ;  there  are  about  seven- 
teen of  these  acids  with  which  we  are  concerned  as  making  up  the 
common  proteins,  and  it  has  been  estimated  that  millions  of  differ- 
ent combinations  can  be  made  by  using  even  one  representative  of 
each  of  these  units.  "  Hence,"  to  quote  Dr.  Rose,^  "  we  have  milk, 
meat,  fish,  eggs,  cereal  and  vegetable  proteins,  all  built  from  the 
same  building  stones  or  the  same  letters  of  the  protein  alphabet, 
containing  therefore  all  the  essentials  for  constructing  different 
kinds  of  body  protein,  as  circumstances  may  require."  "  Such 
proteins  are  called  *  complete.'  "  Another  group  of  proteins, 
while  containing  some  of  the  essential  amino  acids,  lack  others,  so 
that  they  cannot  be  used  under  all  circumstances.  In  children, 
for  example,  there  is  the  element  of  growth  which  must  be 
accounted  for,  and  science  has  made  it  clear  that  growth  can  be 
brought  about  only  by  the  giving  of  a  diet  composed  of  foods  con- 
taining complete  amino  acids.  The  best  examples  of  the  incom- 
plete amino  acids  may  be  found  in  gelatine  and  certain  vegetable 
proteins  found  in  beans  and  peas. 

A  brief  description  of  some  of  the  more  important  proteins  with 
which  we  are  chiefly  concerned  will  serve  to  simplify  the  formula- 
tion of  a  diet.  Those  assuming  the  most  important  position  in 
nutrition  and  food  are  globulins,  albumens,  nucleoproteins, 
phosphoproteins,  hemoglobins,  and  derived  proteins  such  as 
proteoses  and  peptones.  The  albumens  and  globulins  associated 
together  occur  both  in  the  tissues  of  animals  and  in  plants.  The 
albumens  are  richer  in  sulphur  than  the  globulins  and  are  found 
more  abundantly  in  the  animal  fluids,  such  as  the  blood,  while  the 
globulins  predominate  in  the  more  solid  tissues  of  animals  and  in 
plants.     The  close  association  of  these  two  proteins  is  particularly 

•Quoted  from  "Feeding  the  Family,"  by  Mary  Swartz  Rose. 


14  DIETETICS  FOR  NURSES 

noticeable  in  the  blood  and  cells.  They  have  different  char- 
acteristics, however.  The  albumens  are  soluble  in  pure  water, 
while  the  globulins  are  not.  Alcohol-soluble  proteins  are  important 
because  they  constitute  the  principal  part  of  the  protein  of  the 
cereal  grains.  Wheat  flour,  for  example,  is  composed  largely  of 
two  proteins,  glutenin  and  gliadin,  which  combine  to  make  up  the 
gluten  of  wheat.  Bread  owes  its  elasticity  to  the  gluten,  hence  the 
palatability  of  the  loaf  is  determined  by  the  proportions  of  gliadin 
and  glutenin  present.  Analyses  made  of  bread  and  of  flour  have 
proved  that  the  best  bread  is  produced  from  flour  composed  of 
twice  as  much  gliadin  as  glutenin. 

Albuminoids.  —  These  substances  represent  one  group  of  incom- 
plete proteins,  inasmuch  as  they  cannot  alone  support  protein 
metabolism.  However,  they  are  classed  with  the  proteins  and  may 
be  substituted  for  at  least  a  part  of  these  compounds  in  the  daily 
dietary,  since  they  are  able  to  do  much  of  the  work  of  the  pure 
proteins.  The  best  example  of  this  group  is  seen  in  gelatine.  This 
substance  contains  many  of  the  structural  units  of  meat  protein 
but  in  very  different  relative  amounts.  It  has  not,  therefore,  the 
chemical  units  necessary  to  repair  the  worn-out  parts  of  cell 
machinery.^ 

Nucleoproteins  are  abundant  in  the  highly  nucleated  cells  of  the 
glandular  organs,  such  as  the  pancreas,  the  liver,  and  the  thjonus 
gland.  They  are  composed  of  a  simple  protein  with  nucleic  acid. 
Under  the  influence  of  gastric  digestion  these  compounds  split  to 
the  two  constituents  protein  and  nuclein.  Nucleic  acid  is  rich  in 
phosphorus  and  upon  decomposition  yields  some  of  the  purin  bases 
(xanthin,  adenin,  guanin,  etc.),  a  carbohydrate,  and  phosphoric 
acid. 

Phosphoproteins,  as  has  been  already  described,  are  compounds 
of  simple  proteins  with  some  form  of  phosphorus.  The  best 
examples  of  these  proteins  are  found  in  the  yolk  of  egg,  where  it 
occurs  as  ovovitellin,  and  in  the  casein  of  milk. 

Hemoglobin,  composed  of  simple  proteins  with  hematin  or  like 
substance.     This  is  one  of  the  important  constituents  of  the  blood, 

'"The  Basis  of  Nutrition,"  by  Graham  Lusk. 


FOOD  15 

acting  as  a  carrier  of  oxygen  from  the  air  by  way  of  the  lungs  to 
the  tissues. 

WATER 

This  chemical  combination,  belonging  to  the  inorganic  food 
group  and  unable  to  furnish  the  body  with  fuel  or  build  and  repair 
its  tissues,  is  nevertheless  equally  as  important  as  any  of  the  other 
foodstuffs  belonging  to  the  organic  group  because  of  its  entrance 
into  every  tissue,  organ,  and  function  of  the  body  and  of  food. 
Man  can  exist  for  days,  even  weeks,  without  food,  but  without 
water  life  is  soon  extinct.  This  substance  is  composed  of  hydrogen 
and  oxygen  in  the  proportion  of  two  to  one ;  that  is,  to  each  atom  of 
oxygen  there  will  be  found  two  atoms  of  hydrogen.  This  is  always 
the  case  no  matter  where  it  is  found.  When  foods  are  put  through 
a  drying  process  the  water  is  taken  out  and  the  rest  of  the  chemical 
composition  of  the  food  remains  unchanged. 

MINERAL  MATTER 

Ash.  —  The  eight  remaining  chemical  elements,  i.e.,  calcium, 
magnesium,  sulphur,  iron,  sodium,  potassium,  phosphorus,  chlorine, 
constituting  the  mineral  salts  or  ash,  are  likewise  classed  as  food  on 
account  of  the  work  which  they  perform  in  the  body.  Some  of 
these  elements  enter  the  body  as  essential  constituents  of  the 
organic  compounds,  and  are  metabolized  in  the  body  as  such, 
becoming  inorganic  only  upon  oxidation  of  the  organic  materials  of 
which  they  form  a  part. 

Those  which  may  be  mentioned  as  such  are  iron,  sulphur,  and 
phosphorus.  Other  elements  belonging  to  this  group  both  enter 
and  leave  the  body  in  the  same  inorganic  form.  Physiological 
chemists  are  proving  more  and  more  the  importance  of  the  ash 
constituents  in  human  nutrition,  hence  it  is  necessary  for  the  nurse 
to  know  just  where  these  elements  can  be  found  and  in  what  form 
they  are  distributed.  For  this  purpose  the  following  table,  com- 
piled from  one  arranged  by  Sherman,^  is  included : 

'  "Chemistry  of  Food  and  Nutrition,"  p.  332,  by  Henry  Sherman. 


16 


DIETETICS  FOR  NURSES 


TABLE   V 
Ash  Constituents  of  Foods  in  Edible  Portions  ^ 


Food 

CaO 

MgO 

K,0 

Na^O 

P2O2 

CI 

S 

Fe 

Apples     .     .     .     . 

.014 

.35 

.15 

.02 

.03 

.004 

.005 

.0003 

Asparagus    .     .     . 

.04 

.02 

.20 

.01 

.09 

.04 

.04 

.0010 

Bananas  .     .     .     . 

.01 

.04 

.50 

.02 

.055 

.20 

.013 

.0006 

Barley  (pearled)    . 

.025 

.10 

.35 

.04 

.46 

.02 

.0013 

Beans  (dried)    .     . 

.22 

.25 

1.40 

.26 

1.14 

.03 

.22 

.0070 

Beans  (Lima)   .     . 

.10 

.31 

2.1 

.33 

.77 

.025 

.16 

.0070 

Beans  (fresh)    .     . 

.04 

.11 

.7 

.12 

.27 

.009 

.06 

.0025 

Beans  (string)  .     . 

.075 

.043 

.28 

.03 

.12 

.04 

.0016 

Beef 

Beer 

.007 

.010 

.059 

.059 

.089 

.014 

Beets 

.03 

.033 

.45 

.10 

.09 

.04 

.015 

.0006 

Blueberries  .     .     . 

.045 

.015 

.05 

.02 

Blackberries      .     . 

.08 

.035 

.20 

.08 

.01 

Bread,  white     .     . 

.03 

.03 

.10 

.20 

.12 

.0009 

Bread,  wholewheat 

.04 

.08 

.27 

.4 

.0015 

Butter     .     .     .     . 

.02 

.001 

.02 

.03 

Buttermilk        .     . 

.15 

.026 

.18 

.08 

.22 

.10 

Cabbage .... 

.068 

.026 

.45 

.05 

.09 

.03 

.07 

.0011 

Cocoa      .... 

.14 

.48 

1. 

.05 

1.1 

.04 

.0024 

Carrots    .... 

.077 

.034 

.35 

.13 

.10 

.036 

.022 

.0008 

Cauliflower  .     .     . 

.17 

.02 

.27 

.10 

.14 

.05 

.085 

Celery      .... 

.10 

.04 

.37 

.11 

.10 

.025 

.0005 

Cheese     .... 

1.1 

.06 

.2 

1. 

1.45 

1. 

Cheese  (cottage)   . 

.3 

.015 

.5 

Chocolate     .     .     . 

.14 

.48 

.90 

Cocoanut     .     .     . 

.09 

.10 

.77 

.10 

.38 

.25 

Codfish    .... 

.2 

Coffee      .... 

.25 

.42 

2.3 

.08 

.054 

.04 

Corn  (fresh)      .     . 

.008 

.055 

.137 

.05 

.22 

.014 

.044 

.0008 

Cornmeal     .     .     . 

.015 

.13 

.17 

.03 

.3 

.116 

.0011 

Crackers       .     .     . 

.025 

.017 

.12 

.23 

.12 

.0015 

Cream     .... 

.14 

.02 

.15 

.06 

.18 

.1 

.03 

.0002 

Cucumbers  .     .     . 

.022 

.015 

.17 

.015 

.08 

.03 

.022 

Dandelion  greens  . 

.0027 

Dates       .... 

.10 

.12 

.003 

Eggs 

.093 

.015 

.165 

.2 

.37 

.10 

.19 

.003 

Egg,  white  .     .     . 

.015 

.015 

.19 

.21 

.03 

.15 

.196 

.0001 

Egg,  yolk     .     .     . 

.2 

.02 

.13 

.1 

1.0 

.1 

.157 

.0085 

Figs,  dried    .     .     . 

.299 

.145 

1.478 

.064 

.332 

.056 

.0032 

Fish  (halibut)  .     . 

.013 

.4 

.0003 

Grapefruit    .     .     . 

.03 

.02 

.17 

.04 

.01 

.0004 

Grapes     .... 

.024 

.014 

.25 

.03 

.12 

.01 

.024 

.0013 

Grape  juice       .     . 

.021 

.016 

.20 

.01 

.04 

.01 

* 

FOOD 
TABLE  V  — Continued 


17 


Food 

CaO 

MgO 

K,0 

Na20 

P2O2 

C 

s 

Fe 

Honey     .     .     .     . 

.005 

.03 

.5 

.04 

.03 

.0010 

Lamb       .     . 

Lemon  juice 

.033 

.01 

.17 

.01 

.025 

.01 

Lentils     .     . 

.12 

.05 

.75 

.25 

.66 

.08 

.0086 

Lettuce    .     . 

.05 

.01 

.42 

.04 

.09 

.06 

.014 

.001 

Meat  10 

Lean  beef 

.011 

.04 

.42 

.09 

.50 

.05 

.20 

.0038 

Lean  veal 

.016 

.045 

.46 

.12 

.50 

.07 

.23 

Chicken    . 

.015 

.06 

.56 

.13 

.58 

.06 

.216 

Lean  pork 

.012 

.046 

.34 

.13 

.45 

.05 

.20 

Milk   .     .     . 

.168 

.019 

.171 

.068 

.215 

.12 

.033 

.00024 

Molasses 

.9 

.3 

1.7 

.3 

.2 

.2 

Oatmeal  .     . 

.13 

.212 

.458 

.109 

.872 

.035 

.215 

.0036 

Onions     .     . 

.06 

.03 

.23 

.02 

.12 

.02 

.06 

.0005 

Oranges  .     . 

.06 

.02 

.22 

.01 

.05 

.01 

.013 

.0003 

Orange  juice 

.05 

.02 

.22 

.01 

.03 

.01 

Parsnips  .     . 

.09 

.07 

.70 

.01 

.19 

.03 

Peaches  .     . 

.01 

.02 

.25 

.02 

.045 

.01 

.01 

.0003 

Peanuts  .     . 

.10 

.28 

.85 

.07 

.90 

.04 

.243 

.0020 

Pears  .     .     . 

.021 

.019 

.16 

.03 

.06 

.0003 

Peas  (dried) 

.04 

.07 

.30 

.04 

.26 

.01 

.06 

.0016 

Pineapple     . 

.02 

.02 

.38 

.02 

.06 

.05 

.0005 

Potatoes  (sweet 

)    '. 

.016 

.036 

.53 

.025 

.140 

.03 

.03 

.0013 

Rhubarb       . 

.06 

.02 

.39 

.03 

.07 

.035 

Rice    .     .     . 

.012 

.145 

.084 

.028 

.203 

.05 

.105 

.0009 

Spinach   .     . 

.09 

.08 

.94 

.20 

.13 

.02 

.041 

.0039 

Squash     .     . 

.02 

.01 

.05 

.05 

.08 

.01 

.026 

.0008 

Strawberries 

.05 

.03 

.18 

.07 

.064 

.01 

.0009 

Tomatoes 

.020 

.017 

.35 

.01 

.059 

.03 

.02 

.0004 

Turnips   .     . 

.089 

.028 

.40 

.08 

.117 

.04 

.07 

.0005 

Turnip  tops 

.48 

.05 

.37 

.11 

.11 

.17 

.07 

Wheat  flour 

.025 

.027 

.146 

.04 

.20 

.07 

.17 

.0013 

Wheat  bran 

.14 

.84 

1.5 

.07 

3. 

.26 

Wine  .     .     . 

.012 

.019 

.100 

.018 

.036 

.01 

VITAMINES 

Before  leaving  the  subject  of  the  foodstuffs,  it  is  necessary  to 
make  some  mention  of  the  accessory  food  substances  known  as 
vitamines.     It  is  a  fact  well  known  to  science  that  the  human  body 

9  Compiled  from  Sherman's  "Chemistry  of  Food  and  Nutrition,"  and  other 
sources. 

10  Average  meat  is  calculated  to  contain  per  100  grams  protein  .075  CaO,  .2  MgO, 
2.0  K2O,  .4  Na20,  2.3  P2O2,  .2  CI,  .9  S,  .015  Fe. 

C 


18  DIETETICS  FOR  NURSES 

needs  something  more  than  absolutely  pure  protein,  fat,  carbohy- 
drate, and  mineral  salts.  When  these  foodstuffs  are  too  highly 
refined  they  seem  to  lose  some  vital  quality  which  alone  produces 
growth.  It  is  only  recently  that  these  substances  have  been 
recognized  and  studied.  That  they  exist  in  minute  quantities  in 
a  number  of  foods  is  certain,  but  very  little  is  really  known  as  to 
their  exact  character.  It  is  only  known  that  if  a  young  animal 
is  given  food  deficient  in  these  so-called  vitamines  he  will  cease  to 
grow.  Certain  nutritional  diseases  are  believed  to  be  due  to  an 
absence  of  vitamines  in  the  food  of  the  individual.  In  certain 
countries  the  disease  beri-beri  was  prevalent,  and  upon  investiga- 
tion it  was  noted  that  those  suffering  from  the  disease  subsisted 
upon  rice  from  which  the  outer  husk  had  been  removed.  Rose  ^^ 
states  that  individuals  restricted  to  a  diet  of  cooked  and  dried 
rations,  especially  if  limited  in  variety,  run  a  risk  of  developing 
scurvy,  one  of  the  diseases  also  considered  to  be  due  to  a  lack  of 
vitamines  in  the  diet.  According  to  Lusk,!^  there  are  certain  classes 
of  vitamines  existing  in  the  vegetable  kingdom  which  are  necessary 
for  the  normal  growth  and  nutrition  of  animal  tissue,  and  since 
they  become  a  part  of  the  tissue  it  would  be  unnecessary  to  eat  the 
vegetable  if  the  meat  were  eaten.  It  has  been  said  that  there  is  a 
deficiency  of  the  neuritis-preventing  substances  in  the  composition 
of  sweet  potatoes,  Irish  potatoes,  and  some  of  the  breakfast  foods, 
and  that  meat  sterilized  at  a  high  temperature  will  also  lose  these 
substances.  There  has  been  more  or  less  discussion  as  to  the 
advisability  of  sterilizing,  by  boiling,  milk  to  be  used  in  the  feeding 
of  infants,  since  there  is  a  liability  of  the  vitamines  being  destroyed 
if  they  are  subjected  to  this  degree  of  temperature.  In  America 
it  is  not  probable  that  adults  under  normal  conditions  will  confine 
themselves  to  a  diet  deficient  in  vitamines.  Hence  we  run  few 
chances  of  developing  scurvy  or  beri-beri,  but  babies  kept  upon  a 
diet  consisting  of  dried  prepared  foods  and  milk  which  has  been 
boiled  run  a  risk  of  developing  scUrvy,  which  is,  according  to  many 
authorities,  directly  due  to  the  absence  of  these  accessory  food  sub- 

"  "Feeding  the  Family,"  Mary  Swartz  Rose. 

w  " Fundamental  Basis  of  Nutrition,"  Graham  Lusk. 


FOOD  •  19 

stances.  The  addition  of  fresh  foods/^  especially  fruits  and  vege- 
tables such  as  oranges,  lemons,  potatoes,  and  cabbage,  will  prevent 
or  even  cure  these  diseases  should  they  chance  to  develop. 

A  brief  description  of  the  foods  especially  valuable  in  the  invalid 
dietary  may  be  useful  to  the  nurse  in  the  formulation  of  diets  in 
different  pathological  conditions. 

Eggs.  —  The  table  shows  eggs  to  have  a  chemical  composition 
of  water  73.7%,  protein  14.8%,  fat  10.5%,  and  mineral  salts  (ash) 
1.0%.  Fuel  value  per  pound,  672  calories.  The  white  of  the  egg, 
constituting  57%  of  the  entire  weight,  is  composed  chiefly  of 
albumen  and  water  with  a  small  percentage  of  mineral  salts  in  the 
form  of  calcium,  potassium,  magnesium,  sodium,  phosphorus, 
chlorine,  sulphur,  and  iron.  Typical  albumens  are  always  rich  in 
sulphur,  and  in  eggs  the  sulphur  content  is  much  greater  in  the  egg 
white  than  it  is  in  the  yolk.  The  yolk  of  eggs  contains  more  pro- 
tein and  fat  than  the  white,  and  less  water.  The  protein  of  the 
yolk  is  chiefly  in  the  form  of  ovovitellin,  while  the  fats  occur  as 
palmitin,-  olein,  and  stearin.  There  is  also  5%  of  coloring  matter 
in  the  yolk  of  eggs  besides  lecithin,  nuclein,  salts  of  iron,  potas- 
sium, magnesium,  and  phosphorus.  The  latter  mineral  salt  com- 
prises 1.0%  in  yolk,  while  in  the  white  there  is  only  .03%.  Eggs 
have  a  position  in  the  invalid  dietary  second  only  to  that  of  milk. 
They  are  nutritious,  easy  of  digestion,  and  exceedingly  palatable 
if  properly  selected  and  correctly  prepared.  The  albumen  in  the 
white  is  very  susceptible  to  the  effect  of  heat.  At  a  temperature 
of  about  135°  F.  the  clear,  pale  yellowish  white  begins  to  change  to 
an  opalescent  tint,  and,  as  the  temperature  is  gradually  increased, 
the  texture  changes  from  a  viscid,  sticky  substance  to  an  opaque, 
jellylike  mass  which  solidifies  with  an  ever  increasing  temperature. 
Hard  cooked  white  of  egg,  unless  it  is  very  finely  divided,  is  con- 
sidered difficult  of  digestion,  but  if  the  heat  is  applied  gradually 
and  is  not  raised  to  the  boiling  point  (212°  F.)  there  is  no  reason 
why  the  hard  cooked  white  of  the  egg  should  not  be  digested. 
However,  it  is  unwise  to  cook  eggs  in  this  manner  for  invalids  or 
children.     Any  of  the  other  methods,  with  the  exception  of  frying, 

18  See  " Treatment  of  Scurvy,"  p.  201. 


20  DIETETICS  FOR  NURSES 

which  should  never  be  used,  is  decidedly  preferable.  Egg  albumen 
is  soluble  in  water  and  fresh  fruit  juices,  so  that  it  may  be  used 
with  great  success  as  a  reinforcing  agent.  In  fact,  the  whole  egg 
may  be  so  used,  but  it  is  more  difficult  to  disguise  the  yolk  in  a 
beverage  than  it  is  the  white,  and  for  this  reason  it  is  not  so  adapt- 
able in  many  cases.  Eggs  may  be  cooked  by  the  following  methods 
in  the  invalid  dietary:  coddled,  soft  cooked,  poached,  creamed, 
omelet,  scrambled,  or  in  custard.  Uncooked  eggs  maybe  given  in 
water,  milk,  wine,  or  fruit  juices. 

Meats.  —  The  flesh  of  animals,  poultry,  and  fish  comes  under 
the  head  of  meat.  These  food  materials  form  one  of  the  most  im- 
portant sources  of  protein  in  the  diet,  the  foodstuff  being  in  con- 
centrated form  easily  handled  by  the  digestive  apparatus  and 
absorbed  almost  completely,  leaving  little  residue  in  the  intestinal 
tract.  The  chemical  composition  of  different  meats  is  very  much 
alike,  as  will  be  seen  in  the  table,  the  bulk  of  the  weight  being 
water,  while  the  proteins  range  from  18.3%  (E.P.)^^  in  beef  to  9.9% 
in  bacon.  The  fats  range  from  17.9%  in  beef  to  64.8%  in  smoked 
bacon. 

The  mineral  salts  or  ash,  as  they  are  found  in  meat : 
"  Sodium  occurs  in  the  animal  body  chiefly  as  chloride  in  the 
fluids  and  blood,  and  to  a  less  extent  in  the  other  tissues."  "  Potas- 
sium, on  the  other  hand,  is  much  more  abundant  in  the  soft  solid 
tissues,  in  the  corpuscles  of  the  blood  and  the  protoplasm  of  the 
muscles  and  other  organs."  "  Potassium  sulphate  in  the  blood 
reacts  to  some  extent  with  sodium  chloride,  forming  potassium 
chloride  and  sodium  sulphate,  both  of  which  are  rapidly  eliminated 
by  the  kidneys."  The  greater  part  of  the  sulphur  with  which  we 
are  concerned  in  nutrition  enters  the  body  by  way  of  the  protein, 
the  percentage  in  lean  beef  being  from  0.95%  to  1.00%.^^  Phos- 
phorus in  meat  occurs  as  phosphoprotein  in  the  nucleoproteins  of 
cell  nuclei,  and  lecithoproteins  in  the  brain  and  to  a  less  extent 
in  other  tissues  as  phosphorized  fats.  Meat  is  poor  in  calcium, 
containing  only  about  0.01  gram  per  hundred  grams  of  substance. 

"  Edible  Portion. 

"  "Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


FOOD  21 

Meat  with  eggs  yields  a  considerable  amount  of  what  is  known  as 
acids  in  the  body,  while  milk  shows  a  predominance  of  base- 
forming  elements. ^^ 

The  cereal  grains  contain  appreciable  amounts  of  protein,  car- 
bohydrates, and,  to  a  less  extent,  fat  (see  table) .  The  cereal  grains 
contain  all  of  the  foodstuffs.  The  proteins,  however,  are  not  in 
every  case  as  available  in  nutrition  as  those  contained  in  milk, 
meat,  and  eggs.^^  From  grain  is  made  the  grits,  meal  and  flour,  also 
the  so-called  "  breakfast  foods  "  or  cereals.  The  protein  content 
of  the  different  grains  ranges  from  12.4%  and  12.5%  in  barley  and 
wheat  to  7.4%  and  9.7%  in  rice  and  corn,  while  the  fats  run  much 
lower  in  all  the  grains,  those  containing  the  largest  amount  being 
oats,  with  a  percentage  of  5,  and  the  lowest  being  rice,  which  has  a 
content  of  0.4%.  The  carbohydrates  predominate  over  all  of  the 
other  foodstuffs  in  grains,  wheat  containing  71.2%,  rice  79.2%, 
oats  59.7%,  corn  (maize)  74.9%,  and  barley  69.8%.  This  type  of 
food  material  forms  a  large  part  of  the  average  dietary,  con- 
stituting the  basis  of  bread,  cake,  pastry,  macaroni,  spaghetti, 
noodles,  crackers,  etc. ;  also  the  breakfast  foods,  such  as  od,tmeal, 
wheatena,  malted  breakfast  foods  of  different  kinds,  hominy, 
grits,  samp,  and  the  ready-to-eat  breakfast  foods,  such  as  corn- 
flakes, wheat  berries,  puffed  rice,  etc. 

In  a  former  chapter  the  effect  of  heat  upon  starch  as  it  occurred 
in  food  was  discussed.  It  is  well,  however,  to  lay  particular  stress 
upon  the  necessity  for  subjecting  those  foods  high  in  cellulose  to  a 
long-continued  cooking,  at  a  lower  temperature  than  that  used  for 
foods  equally  high  in  starch  but  containing  less  cellulose.  In  the 
latter  foods  the  starch  grains  come  in  contact  with  the  heat  more 
quickly  and  more  effectually  than  those  surrounded  by  a  tough 
layer  of  woody  fiber,  which  needs  to  be  broken  down  before  the 
full  effect  of  the  elevation  of  temperature  can  bring  about  the 
desired  change  in  the  starch  itself.  In  the  preparation  of  foods 
containing  starch  for  invalids  and  infants  this  attention  to  the 
chemical  change  in  the  starch  is  especially  essential.     The  fuel 

'*  The  effect  of  meat,  eggs,  and  milk  in  the  body  will  be  dealt  with  in  Section  2. 
"  See  description  of  important  proteins,  p.  13. 


22  DIETETICS  FOR  NURSES 

value  of  the  grains  is  high.  The  table  on  page  144  shows  the  calories 
produced  in  the  body  from  the  oxidation  of  the  grains  and  some  of 
their  important  products,  such  as  bread,  oatmeal,  etc. 

The  fruits  and  vegetables  will  here  be  considered.  Some  of 
the  fruits  and  vegetables  contain  high  percentages  of  sugar,  aside 
from  the  mineral  salts,  for  which  they  are  especially  valuable. 
This  class  includes  the  sugar  cane,  sugar  beet,  raisins,  dates,  figs, 
etc.,  while  others  such  as  the  potato,  taro,  banana,  etc.,  furnish  an 
appreciable  amount  of  starch.  All  of  the  vegetables  and  fruits 
are  rich  in  mineral  salts,  which  are  as  important  to  the  work  of  the 
body  as  the  proteins,  carbohydrates,  and  fats.  Hence  it  is  essen- 
tial to  add  the  foods  containing  these  mineral  salts  to  the  daily 
dietary  either  in  health  or  in  disease. 

The  foods  prized  for  their  fat  content,  aside  from  milk,  meat, 
eggs,  and  grain,  are  olives,  cotton  seed,  peanuts,  etc.  The  fats 
from  these  foods  need  no  especial  mention,  save  to  say  that  in  the 
invalid  dietary  it  is  especially  necessary  to  know  the  amount  of  fat 
contained  in  a  food  before  using  it  too  lavishly,  since  this  foodstuff 
is  more  difficult  for  an  impaired  digestive  apparatus  to  handle  than 
the  others.  It  is  most  valuable  because  it  is  a  concentrated  form 
of  energy-producing  material  and  because  it  is  distributed  through 
the  entire  body,  acting  as  a  protection  to  the  organs  and  giving 
the  human  form  its  graceful  contours,  but,  as  has  already  been 
stated,  the  foods  containing  a  high  percentage  of  fat  in  their 
composition  must  be  judiciously  utilized,  otherwise  much  of  their 
nutrient  will  not  only  be  wasted  in  the  body  through  lack  of 
digestion,  but  may  easily  bring  about  conditions  more  or  less 
serious  in  character.  The  fuel  value  of  the  foods  containing  a 
high  percentage  of  fat  will  be  found  in  the  table  already  mentioned, 
on  page  144. 

Milk.  —  Milk  is  without  a  doubt  the  most  valuable  food  in  the 
invalid  dietary,  furnishing  not  only  a  highly  nutritious  beverage, 
but  likewise  acting  as  a  carrier  of  additional  nourishment  when 
such  is  necessary.  Its  form,  its  lack  of  definite  flavor  and  odor, 
all  add  to  its  value  as  a  food  in  sickness.  Milk  is  one  of  the  few 
foods  which  includes  in  its  composition  all  of  the  chemical  com- 


FOOD  23 

binations  known  as  foodstuffs.  The  carbohydrates,  comprising 
4.88%  to  5%  of  the  solids  in  milk,  occur  as  lactose  or  milk  sugar. 
This  sugar  belongs  to  the  disaccharide  group,  and  is,  in  the  majority 
of  cases,  readily  digested  by  even  the  most  delicate  digestive 
apparatus.  This  form  of  sugar  lends  itself  particularly  well  as  a 
reinforcing  agent,  and  is  generally  used  in  such  cases  as  typhoid 
fever,  etc.  The  fat  in  milk,  comprising  4%  of  the  solids  and  occur- 
ring as  butter  fat  (cream),  is  made  up  chiefly  of  olein  and 
of  palmitin,  with  smaller  amounts  of  stearin  and  from  5%  to  6% 
of  its  composition  in  the  form  of  butyric  acid  (the  fatty  acid  to 
which  butter  owes  its  name  and  flavor)  and  traces  of  other  fatty 
acids,  as  well  as  small  quantities  of  cholesterin,  lecithin,  and  a 
yellow  coloring  matter. 

PROTEINS 

The  proteins  of  milk,  which  form  the  curd  or  larger  part  of  the 
solids,  according  to  Van  Slyke/^  are  in  the  form  of  casein  and 
albumen.  There  are  3.6  parts  casein  to  1  part  soluble  proteins,  but' 
these  figures  vary  somewhat  at  times.  Casein  is  insoluble  in  pure 
water,  but  dissolves  readily  in  water  to  which  an  alkali  or  calcium 
carbonate  is  added.  The  soluble  protein  in  the  form  of  lact- 
albumen  is  one  of  the  constituents  of  whey.  This  substance 
contains  more  sulphur  than  does  casein,  but  no  phosphorus. 

Whey  is  the  opalescent  fluid  which  remains  when  the  casein  is 
precipitated,  and  is  composed  of  water  93.8%,  total  ash  0.44% 
(Konig). 

Mineral  salts,  0.7%  of  milk,  are  made  up  of  calcium,  potassium, 
sodium,  magnesium,  iron,  sulphur,  phosphorus,  and  chlorine. 
Milk  is  so  rich  in  calcium  that  it  requires  only  400  c.  c.  (or  about 
2^  cups)  to  furnish  1  gram  of  calcium.  This  is  the  amount  be- 
lieved to  be  necessary  for  the  welfare  of  man  each  day  and  this 
must  be  derived  from  food.^^ 

Water.  —  The  fluid  part  of  milk  is  composed  chiefly  of  water, 
constituting  87%  of  whole  milk. 

Milk  as  a  food  for  infants  will  be  discussed  in  another  chapter. 

18  "Archives  of  Pediatrics,"  XXII,  515,  by  Van  Slyke. 

w  "Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


24  DIETETICS  FOR  NURSES 

As  has  already  been  said,  no  food  has  so  far  been  discovered 
which  could  be  effectually  substituted  for  milk.  There  is  no  food, 
however,  which  requires  more  attention  in  its  selection  and  care. 
It  is  very  susceptible  to  both  odors  and  flavors,  absorbing  them  both 
readily,  as  will  be  found  if  milk  be  placed  in  the  same  compart- 
ment with  foods  of  strong  odor  and  flavor,  without  being  properly 
covered  and  protected.  This  is  particularly  noticeable  with  cu- 
cumbers, melons,  etc. 

Milk  also  furnishes  a  splendid  medium  for  bacterial  growth, 
and  if  left  exposed  to  the  air,  put  into  unclean  receptacles,  or  kept 
in  a  warm  place,  will  immediately  become  more  or  less  contami- 
nated, after  which  it  is  unwise  to  use  it.  Sterilization  and 
pasteurization  will  in  a  measure  overcome  the  bacterial  contami- 
nation, but  milk  purchased  from  a  dairy  which  is  not  clean  or 
milked  under  unsanitary  conditions  will  remain  dirty,  hence  unfit 
for  human  consumption.  When  the  morning's  milk  supply  is 
.brought  to  the  house  it  should  be  in  clean,  well-stoppered  bottles, 
but  before  placing  it  in  the  icebox  the  tops  of  the  bottles  should  be 
carefully  wiped  off  with  a  wet  cloth  to  remove  any  superficial  dust 
which  may  be  adhering  to  them.  Every  time  a  portion  of  the  milk 
is  removed  thereafter  the  tops  should  be  again  cleansed  before  the 
milk  is  poured  out.  This  is  a  wise  precaution,  and  often  prevents 
contamination  from  the  hands,  etc. 

The  amount  of  water  in  milk  prevents  its  being  an  adequate 
food  for  adults  except  in  certain  pathological  conditions.  How- 
ever, it  furnishes  a  supplementary  food  unequaled  by  any  other 
beverage  known.  There  are  fortunately  only  a  few  individuals 
who  are  unable  to  drink  milk.  There  are  many  who  fancy  they 
cannot  do  so,  but  if  the  nurse  has  the  ingenuity  to  utilize  some  of 
the  various  methods  whereby  milk  is  made  more  digestible, 
it  will  generally  be  found  that  the  patient  can  take  it  without 
trouble.  In  cases  of  personal  dislike,  if  the  milk  is  flavored  or 
colored  or  made  up  into  soup,  cocoa,  chocolate,  junket,  custards, 
blancmange,  etc.,  it  will  usually  prove  acceptable. 

Application  of  Heat.  —  A  word  as  to  the  changes  which  are 
brought  about  as  the  result  of  heat  as  applied  to  milk.     These 


FOOD  25 

changes  are  demonstrated  in  the  two  methods  commonly  used  in 
the  preparation  of  milk  known  as  "  pasteurization  "  and  "  sterili- 
zation." Pasteurization  is  rather  an  indefinite  term  to  use,  unless 
the  time  and  the  temperature  to  which  the  milk  is  subjected  is 
given.  According  to  Morse  and  Talbot  "  the  term  sterilization 
should  never  be  applied  to  the  processes  used  in  the  preparation  of 
milk  for  the  feeding  of  infants,  because  the  milk  is  never  rendered 
bacteriologically  sterile  by  them."  ^^ 

As  a  rule  the  flavor  and  odor  of  milk  is  not  changed  by  heat 
until  the  temperature  reaches  nearly  to  the  boiling  point.  A 
scum  then  forms  on  boiling  milk,  composed  of  casein  50.86%, 
fatty  matter  45.42%,  ash  4.72%  (Rosenau).  Prolonged  boiling 
changes  the  color  of  milk  from  a  creamy  white  to  a  yellowish 
brown  which  deepens  with  boiling.  This  is  due  to  the  caramel- 
ization  of  the  milk  sugar.  Cream  will  not  rise  (or  its  rise  will 
be  very  slow)  on  milk  which  has  been  subjected  to  a  tempera- 
ture of  150°  F.  for  thirty  minutes  or  more  because  the  fat  drop- 
lets are  broken  down  so  that  they  cannot  hold  together  at  that 
temperature  and  become  more  completely  distributed  throughout 
the  fluid.2i 

Pasteurization  is  acknowledged  to  be  preferable  to  sterilization 
in  milk  used  for  infant  feeding  because  the  higher  the  temperature 
the  greater  the  change  in  the  chemical  composition  of  the  fluid. 
According  to  Morse  and  Talbot  ^^  the  temperature  of  the  pasteuri- 
zation should  be  as  low  as  possible.  Pasteurization  at  140°  F. 
for  20  minutes  is  sufficient ;  lower  temperatures  are  not.  "  At 
this  temperature  there  is  no  change  in  the  taste,  odor,  or  color  of 
the  milk,  no  noteworthy  changes  in  the  chemical  composition 
are  produced,  the  ferments  and  bactericidal  action  are  unaffected 
and  bacterial  toxins  and  non-spore-bearing  micro-organisms  are 
destroyed."  ^ 

20  "Diseases  of  Nutrition  and  Infant  Feeding,"  by  Morse  and  Talbot. 

21  Bulletin  56,  Hyg.  Lab.,  Public  Health  Service,  1908 ;  Circular  153,  U.  S.  Dept. 
Agric,  Bureau  of  Animal  Industry,  1910. 

22  "Diseases  of  Nutrition  and  Infant  Feeding,"  p.  173,  by  Morse  and  Talbot. 

23  Quoted  from  "Diseases  of  Nutrition  and  Infant  Feeding,"  p.  173,  by  Morse 
and  Talbot. 


26  DIETETICS  FOR  NURSES 

Rosenau  ^^  states  that  the  bacillus  of  typhoid,  diphtheria,  and 
dysentery,  as  well  as  the  cholera  vibrio  and  other  pathogenic  non- 
spore-bearing  bacteria  which  are  often  found  in  milk,  are  destroyed 
at  a  temperature  of  140°  F.  for  twenty  minutes,  and  at  higher 
temperatures  for  shorter  lengths  of  time. 

Sommerfield's  ^^  investigations  prove  that  butyric  acid  bacilli 
are  destroyed  at  a  temperature  of  212°  F.  to  216°  F.  for  from  1  to 
2  minutes. 

It  must  be  understood  that  no  matter  what  method  is  used  to 
insure  purity  in  milk,  nothing  does  away  with  the  necessity  for 
keeping  the  milk  both  clean  and  cold.  The  receptacles  in  which 
the  milk  is  allowed  to  stand,  the  vessels  in  which  it  is  measured,  and 
the  person  who  handles  it  must  be  absolutely  clean,  and  the  nurse 
must  keep  in  mind  the  fact  that  pasteurization  does  not  completely 
destroy  the  bacterial  growth  in  milk,  that  it  merely  diminishes  it, 
and  she  must  see  that  the  milk  which  has  undergone  the 
pasteurizing  process  is  kept  cold,  otherwise  the  micro-organisms 
which  are  present,  even  if  to  a  less  extent  than  in  raw  milk,  will 
undoubtedly  multiply. 

Adulteration  of  Milk.  —  There  is  not  nearly  so  much  adultera- 
tion of  milk  to-day  as  there  was  a  few  years  ago.  The  stringent 
laws  governing  the  care  and  composition  of  the  milk  make  it  un- 
profitable for  the  dairymen  to  practice  it.  However,  there  are 
times  when  such  things  are  done  and  care  must  be  taken  to  prevent 
it.  Milk  is,  as  has  already  been  stated,  very  susceptible  to  con- 
tamination, and  that  which  is  infected  with  putrefactive  bacteria 
is  not  fit  for  food  even  if  the  dealer  has  doctored  it  with  formalde- 
hyde. However,  the  danger  to-day  is  not  so  much  from  drugs  as 
from  lack  of  care  in  the  handling  of  the  milk.  It  is  well  to 
remember,  however,  that  water  is  an  adulteration  just  the  same 
as  formaldehyde  and  perhaps  more  pernicious,  since  the  quantities 
of  the  latter  are  so  small  in  an  ordinary  quantity  of  milk  as  not  to 
make  a  great  deal  of  difference  except  in  the  feeding  of  invalids  and 

2*  Rosenau  :  Bulletin  56,  Hyg.  Lab.,  Public  Health  Service,  1909;  Circular  153, 
U.  S.  Dept.  Agric,  Bureau  of  Animal  Industry,  1910. 

"  Sommerfield ;  Handbuch  der  Milchkunde,  J.  F.  Bergman,  Weisbaden,  1909. 


FOOD  27 

children,  while  watered  milk  is  a  swindle  not  only  to  the  pocket- 
book  but  to  the  body  also,  since  the  requisite  nutritive  value  is 
lacking. 

Selection  and  Care  of  Milk.  —  There  are  a  few  essential  facts 
to  keep  in  mind  in  regard  to  milk :  (1)  Be  sure  of  the  source  of  the 
milk  supply,  especially  in  the  feeding  of  the  sick  and  of  infants. 
Milk  for  such  cases  should  always  be  purchased  from  inspected 
dairies  when  it  is  possible.  (2)  Keep  the  milk  cold,  the  best  milk 
in  the  world  will  spoil  if  left  in  a  warm  place.  (3)  Always  keep  the 
milk  bottle  well  covered,  thus  eliminating  the  danger  of  con- 
tamination, flies,  etc. 

Skimmed  Milk.  —  Milk  which  has  had  the  cream  removed  is 
still  nutritious,  but  not  so  much  so  as  whole  milk.  Babies  fed 
upon  skimmed  milk  will  grow  thin  unless  fat  is  added  in  some  form. 

Buttermilk  is  milk  which  has  been  soured,  either  naturally  by 
allowing  it  to  stand  in  a  warm  place  until  it  is  soured  and 
coagulated,  or,  by  adding  lactic  acid  bacteria  (Bulgarian  Culture) 
to  bring  about  the  souring  and  coagulation.  Buttermilk  may  be 
made  from  whole  or  skimmed  milk,  but  the  latter  is  thin  and 
watery  and  less  palatable  than  that  made  from  the  milk  with  the 
cream  left  in.  Buttermilk  is  one  of  the  most  wholesome  forms  in 
which  milk  can  be  taken,  and  for  this  reason  is  used  largely  in  the 
invalid  dietary  and  in  the  feeding  of  infants.  Koumiss,  Matzoon, 
Zoolak  are  artificially  fermented  milk,  and  are  used  in  the  feeding 
of  the  sick. 

Whey.  —  Whey  is  an  opalescent  solution  which  remains  after 
the  coagulation  of  casein ;  it  contains  the  greater  part  of  the  lac- 
tose, lactalbumen,  and  ash  constituents  of  milk.  Whey  being  fat 
free  is  used  as  a  substitute  for  part  or  all  of  the  diluents  in  the 
modification  of  milk  for  infants  under  certain  conditions  specified 
by  the  physician. 


CHAPTER  II 

THE  SELECTION,   CARE,   AND  ADULTERATION  OF 

FOOD 

RULES   GOVERNING  SELECTION   OF   FOOD 

There  are  certain  fundamental  rules  to  be  observed  in  the 
selection  of  our  food  materials,  whether  they  are  intended  for 
those  in  health  or  for  those  suffering  from  pathological  condi- 
tions. These  rules  are  definite  and  obligatory.  All  food  mate- 
rials must  be  of  good  quality ;  that  is,  they  must  be  of  known 
purity  and  cleanliness,  and  adulteration  should  not  be  tolerated. 
In  health  the  small  amount  of  preservative  used  in  fcertain 
canned  and  bottled  foods  would  probably  have  little  if  any  effect 
on  the  individual,  but  in  sickness  this  is  not  always  the  case. 
With  regard  to  milk,  this  p>oint  has  particular  significance.  To 
obviate  danger,  the  nurse  should  use  discrimination  in  the  selec- 
tion of  the  dealer  from  whom  the  meat,  milk,  eggs,  fruit,  and 
vegetables  are  purchased,  as  well  as  the  grocer  who  supplies  the 
remainder  of  the  food  materials  used  by  the  patient. 

Dairy  Products.  —  Milk,  cream,  and  other  dairy  products  form 
such  an  important  part  of  the  invalid  dietary  that  they  require 
especial  care  in  their  selection.  "  Certified  Milk  "  is  the  safest. 
This  is  protected  by  special  inspection.  The  methods  and 
standards  governing  the  production  and  distribution  of  certified 
milk  were  adopted  by  the  American  Association  of  Medical 
Milk  Commissions,  May  1,  1912.  The  sanitary  condition  of  the 
dairy,  the  cleanliness  of  the  vessels  into  which  the  milk  is  placed, 
the  health  of  the  milkers,  and  a  surety  that  no  member  of  their 
family  with  whom  they  come  in  contact  has  any  kind  of  contagious 
disease,  are  all  obligatory.  The  feed  for  the  cows  and  the  purity 
of  the  water  given  them  to  drink  must  be  inspected  and  made  to 
conform  to  the  standard  laid  down  for  certified  milk.  The  milk 
of  sick  cows  and  those  having  tuberculosis  is  absolutely  con- 

28 


THE  SELECTION  AND  CARE  OF  FOOD     29 

demned.  The  composition  of  certified  milk  is  standardized  as 
follows :  The  fat  standard  shall  be  4%,  with  a  permissible  range 
varying  from  3.5%  to  4.5%.  The  proteins  shall  be  3.5%,  with  a 
permissible  range  varying  from  3%  to  4%.  Certified  milk  shall 
not  contain  more  than  10,000  bacteria  to  the  cubic  centimeter 
when  it  is  delivered.  This  inspection  and  standardizing  necessarily 
raises  the  price  of  certified  milk  above  that  of  milk  not  so  rigidly 
cared  for,  and  when  the  additional  expense  makes  it  impossible 
for  the  patient  to  afford  certified  milk,  the  only  thing  to  do  is  to  be 
sure  of  the  reliability  of  the  dealer  from  whom  the  milk  is  pur- 
chased and  the  cleanliness  of  the  dairy  from  which  it  is  procured. 
Buttermilk  and  butter  are  the  milk  products  which  require  some 
attention  as  to  selection.  The  former  grows  sour  with  age  and  the 
odor  of  advanced  fermentation  and  decomposition  is  readily  recog- 
nized. Sweet  butter,  butter  without  salt,  is  less  apt  to  be  old  when 
purchased  than  the  salted  variety,  as  the  flavor  of  rancid  fat  is 
unmistakable  in  butter  which  has  not  been  especially  treated. 

Vegetables  should  be  fresh  and  free  from  blemishes.  Those  to 
be  served  raw,  such  as  lettuce  and  other  salad  vegetables,  must 
be  purchased  from  reliable  markets.  Unscrupulous  vendors  have 
been  known  to  sprinkle  old  wilted  vegetables,  to  restore  their 
freshness,  with  water  from  stagnant  pools  teeming  with  typhoid 
bacteria,  thereby  spreading  infection  broadcast.  Vegetables  which 
require  cooking  before  they  are  eaten  are,  for  this  reason,  safer. 

Canned  foods  should  be  avoided  in  the  diet  of  the  invalid 
whenever  it  is  possible ;  but,  when  it  is  not,  care  should  be  observed 
that  no  can  is  used  in  which  there  is  the  least  sign  of  fer- 
mentation. Beans  and  peas  are  sometimes  artificially  colored, 
but  this  custom  is  not  so  prevalent  now  as  it  used  to  be. 

Beverages  and  syrups  are  used  constantly  in  the  feeding  of  the 
sick,  and  for  this  reason  should  be  selected  with  the  greatest  care. 
The  nurse  should  be  cautioned  to  read  the  label  on  every  bottle 
to  make  sure  that  it  is  free  from  injurious  substances.  The 
infinitesimal  amount  of  sulphurous  acid  sometimes  put  into 
beverages  to  preserve  them  would  not  be  noticed  by  the  normal 
individual,  but  to  the  patient  suffering  with  gastric  disorder  even 


30 


DIETETICS  FOR  NURSES 


this  small  amount  may  bring  about  an  increased  irritability  of  the 
mucous  lining  of  the  stomach,  resulting  in  acute  pain. 

Th^  meats  to  be  used  for  the  invalid  must  be  selected  with  care. 
The  quality  of  this  item  of  food  is  most  important.  It  is  not  always 
necessary  to  purchase  the  most  expensive  cut.  If  it  is  to  be  broiled 
or  roasted  then  it  is  necessary  to  select  parts  of  the  animal  which 
are  tender,  but  for  broths,  soups,  scraped  or  ground  meat,  or  the 
meat  to  be  used  for  the  juice  only,  it  is  wasteful  to  buy  these 
tender,  expensive  pieces  when  those  costing  less  will  serve  the 
purpose  equally  well.  The  names  given  to  the  different  cuts  vary 
slightly  in  different  parts  of  tfie  country,  but  those  in  general  use 
only  will  be  mentioned  here.  The  following  diagram  shows  the 
manner  in  which  the  beef  is  'cut  and  the  method  in  which  it  is 
generally  used  : 

TABLE  VI 


Beef 

Cut 

Method  of  Preparation 

Hindquarter 

r  more  or  less  free 

Broth,  soup,  beef  juice,  scraped 

Round  <      from  fat 

beef. 

. 

[  round  steak 

Hamburg  steak  (ground  meat) 
Broiled  (this  is  a  cheaper  and 

less  tender  cut  than  the  loin 

steaks). 

'  steak 

Broiled,  cheaper  cut  steak. 

Rump  \ 

roast 

Roasted,  cheaper  cut  roast. 

lean  meat 

Broth,  soup,  beef  juice. 

f  3  ribs,  1st,  2d  and 

Roasted. 

Loin 

3d ;  cuts 
sirloin  steak 

Broiled. 

porterhouse  steak 

Broiled. 

steak 

Broiled. 

Tenderloin 

roast 
fillet 

Roasted. 

Broiled  or  roasted,  larded  or 

plain. 

Ribs  (prime) 

Roasted. 

Ribs,  chuck  roast  or  steak 

Roasted  or  broiled. 

Forequarter 

Brisket 

Corning. 

Broth,    soup,    scraped,    meat 

juice. 
Hamburg  steak. 
Salisbury  steak. 

THE  SELECTION  AND   CARE   OF  FOOD 

Cuts  of  Lamb  and  Mutton 


31 


Lamb 

Neck 

Soup,  broth,  etc. 

Chuck  (including  shoulder 

ribs).      Shoulder 

chops 

are  not  so  tender 

as  loin 

chops. 

Broiled. 

Flank 

Soup,  broth. 

Loin  (chops) 

Broiled. 

Leg 

Roasted. 

Veal 

Neck 

Soup,  broth. 

Chuck 

Soup,  broth,  roast,  broiled. 

Cutlets 

Broiled  (breaded  or  plain). 

Chops  (rib) 

Broiled. 

Breast 

Roasted,  stuffed  or  plain. 

Leg 

Roasted. 

Hind  shank  ,       , ,        , ,    , 
Fore  shank  (^^^l'^""'^*^) 

Soup,  broth. 

Pork  in  the  Diet.  —  Frpsh  pork  is  rarely  ever  included  in  the 
invalid  dietary  save  in  diabetic  diets.  Meat  from  this  animal  must 
always  be  thoroughly  cooked,  not  only  because  underdone  pork 
is  exceedingly  indigestible  but  because  there  is  an  infectious  bacte- 
rium sometimes  found  in  pork  which  is  only  destroyed  by  thorough 
cooking  of  the  meat.  Well-cooked  bacon  is  digestible  if  the  surplus 
fat  is  poured  off  instead  of  allowed  to  soak  into  the  cooked  bacon. 
The  most  efficient  method  of  cooking  bacon  is  to  place  the  strips 
upon  a  broiler  under  the  flame.  In  this  way  the  hot  fat  drips  down 
into  the  pan  beneath,  leaving  the  bacon  crisp  and  delicate. 

Quality  of  Meats.  —  The  quality  of  meat  depends  upon  several 
factors :  age,  sex,  care,  feeding,  and  the  length  of  time  it  is  hung. 
Cold  storage  beef  is  much  more  apt  to  be  tender  than  that  cut 
from  a  freshly  killed  animal.  Animals  that  are  not  allowed  to 
run  over  a  large  area,  but  are  kept  in  a  small  inclosure  and  fed 
on  fattening  foods,  produce  meat  of  a  high  quality.  This  is 
because  the  muscular  tissue  has  not  been  hardened  with  exercise. 
The  worked  muscle  is  always  tougher  than  the  quiet  one.  For 
this  reason  the  tenderloin  of  beef  is  more  tender  than  the  flank. 
It  is  situated  in  the  part  of  the  animal  that  is  exercised  the  least. 
The  tough  parts,  however,  are  not  lacking  in  flavor  or  nourishment, 


32  DIETETICS  FOR  NURSES 

but  the  manner  in  which  they  must  be  cooked  to  assure  them  of 
being  tender  deprives  them  of  much  of  their  original  flavor.  This 
is  demonstrated  in  broths  and  soups  made  from  the  tough  cuts 
of  meat.  The  extractives  from  which  meat  derives  its  flavor 
and  the  soluble  albumens  are  drawn  out  by  the  water,  and  if 
it  is  to  be  used  as  hash,  croquettes,  etc.,  needs  to  be  seasoned, 
since  the  broth,  while  it  has  taken  very  little  of  the  actual  nourish- 
ment from  the  meat,  has  deprived  it  of  practically  all  of  its  flavor. 
In  making  broth  or  soup,  if  the  meat  is  covered  with  cold  water 
instead  of  hot,  more  of  the  extractives  will  be  drawn  out  and  the 
broth  will  be  more  highly  flavored  and  much  more  stimulating. 
The  color,  odor,  and  freshness  of  the  muscular  and  fatty  tissues  of 
meat  are  all  indicative  of  their  quality.  Fresh  meat  is  firm  in 
texture  and  free  from  offensive  odor.  Stale  beef  and  that  cut  from 
an  old  steer  exhales  a  pungent  odor  of  butyric  acid.  The  color  of 
beef  should  be  dark  purplish  when  fresh  cut  but  this  changes 
quickly  to  a  bright  red ;  it  should  contain  preservatives  of  no  kind 
and  must  be  cut  from  animals  free  from  all  disease.  The  fat 
should  be  of  a  yellowish  white  and  be  crumbly,  and  should  be 
distributed  throughout  the  muscular  tissue  and  around  the  organs. 

Veal,  being  the  flesh  of  an  immature  creature,  is  not  so  highly 
flavored  as  the  flesh  of  older  animals,  but  the  bones  and  cartilages 
are  softer,  and  when  this  meat  is  used  for  broth,  more  of  the 
gelatine  (collagen  and  elastin  from  the  bones  and  connective 
tissue)  is  dissolved  out,  giving  a  slightly  higher  percentage  of 
nutriment  in  the  broth. 

Selecting  of  Chicken  and  Turkey.  —  In  selecting  chicken  for 
the  diet  of  invalids,  use  only  the  young  birds  for  broiling,  those  a 
few  months  older  for  baking  and  roasting,  and  the  fowls  for  soup 
and  broth.  To  test  a  chicken  for  broiling  and  roasting,  select  one 
in  which  the  cartilage  at  the  end  of  the  breastbone  is  soft  and 
pliable ;  the  pinions  (lower  part  of  the  wings)  and  the  feet  should  be 
soft  and  readily  bent.  The  breastbone  of  a  fowl  is  firmer  and  the 
wings  and  feet  harder  than  those  of  the  younger  chicken.  The 
young  chicken  has  an  abundance  of  pin  feathers  while  the  old  fowl 
has  not.     In  fact,  one  of  the  means  of  differentiating  between  the 


THE  SELECTION  AND  CARE   OF  FOOD  33 

old  chicken  and  the  young,  even  if  they  are  practically  of  the  same 
weight,  is  the  presence  of  the  long  hairs  instead  of  pin  feathers. 
The  fowl  selected  for  broth  should  not  be  very  fat,  as  this  fat  will 
melt  into  the  broth,  causing  it  to  be  greasy  and  unpalatable. 
Turkey,  even  when  it  is  young,  is  not  quite  so  digestible  as  young 
chicken;  the  fibers  are  longer  and  the  connective  tissue  more 
abundant.  Goose  and  duck  are  richer  in  fat  and  not  so  desirable 
as  chicken  in  the  invalid  dietary.  Squab,  quail,  and  young 
squirrel  are  all  palatable  and  readily  digested.  The  squirrel 
must,  however,  be  young,  or  the  flesh  will  be  tough  and  more  difii- 
cult  of  digestion. 

Fish.  —  Fish  should  be  given  consideration  in  the  dietary  of  the 
invalid  since  it  is  a  valuable  source  of  protein  and  readily  digested 
in  the  majority  of  cases.  As  a  rule  fish  is  not  so  well  liked  as  meat, 
but  since  it  contains  a  smaller  percentage  of  extractives  and  purin 
bases  it  is  exceedingly  valuable  in  certain  pathological  conditions. 
The  lean  varieties  of  fish,  halibut,  flounder,  trout,  perch,  haddock, 
turbot,  whitefish,  are  more  readily  digested  than  the  dark  fish, 
which  contain  a  higher  percentage  of  fat.  To  this  latter  class 
belong  the  bluefish,  mackerel,  salmon,  shad,  and  herring. 

Shellfish.  —  Of  the  shellfish,  the  oyster  and  the  clam  are 
exceedingly  useful.  The  soft  parts  of  the  oyster  are  palatable  and 
easily  digested.  They  are  not  highly  nutritious,  but  give  a  nice 
variety  to  the  diet.  When  used  in  broth  or  for  the  juice,  clams  are 
particularly  useful.  Many  cases  of  nausea  are  relieved  by  the 
taking  of  iced  or  very  hot  clam  juice  when  they  resist  other 
remedies.  The  necessity  of  having  both  oysters  and  clams 
absolutely  fresh  is  of  the  greatest  importance,  since  a  type  of  poison 
results  from  tainted  shellfish  which  is  exceedingly  dangerous. 

Eggs.  —  The  selection  of  eggs  is  equally  as  important  as  the 
selection  of  other  foods.  There  are  "  new-laid  eggs,"  "  fresh 
eggs,"  and  just  "  eggs."  The  latter  are  generally  storage  and 
should  not  be  used  for  the  sick  or  for  infants.  As  a  rule  old  eggs 
will  not  stand  poaching,  the  whites  and  yolks  mingle  and  form  an 
unappetizing  mass.  It  does  not  make  any  difference  whether  the 
color  of  the  shell  is  white  or  brown ;  if  the  egg  is  absolutely  fresh 


34  DIETETICS  FOR  NURSES 

the  white  and  yolk  should  be  distinct  and  easily  separated,  and 
when  they  are  not  it  is  safer  to  discard  the  egg  entirely. 

THE  CARE  OF  FOODS  AND  UTENSILS 

The  next  point  of  consideration  is  the  care  of  the  food  materials. 
This  is  quite  as  important  as  the  selection,  for  even  the  best  of 
food  may  be  ruined  by  careless  handling,  not  only  in  the  prepara- 
tion, but  likewise  during  the  period  before  it  is  prepared  for  the 
invalid's  consumption.  The  rules  governing  the  handling  of  food 
materials  before  they  reach  the  consumer  are  subject  to  inspection 
by  law,  but  the  housekeeper  or  nurse  has  no  such  rules  to  guard  or 
govern  her ;  hence  she  may  be  wantonly  careless  or  ignorantly  un- 
sanitary unless  taught  the  right  way  to  care  for  the  food  in  her 
charge.  Perishable  fruits  and  vegetables  must  be  kept  in  a  cool 
place  to  preserve  their  freshness.  Milk  and  milk  products,  cream, 
butter,  buttermilk,  cheese,  etc.,  meat,  fish,  and,  at  times,  eggs  should 
be  kept  in  a  refrigerator  or  in  a  cold  place  such  as  the  cellar  in  the 
country,  when  it  is  impossible  to  procure  ice. 

Broths  of  all  sorts,  beef  juice,  and  meat  jellies  will  sour  and  de- 
compose unless  kept  close  to  the  ice.  Carbonated  waters,  such 
as  Vichy,  ApoUinaris,  White  Rock,  etc.,  as  well  as  champagne  and 
other  sparkling  wines,  must  be  kept  in  a  dark,  cool  place,  lying  on 
the  side.  It  is  better  to  put  only  one  or  two  bottles  on  the  ice 
at  a  time,  since  the  wine  flattens  (loses  its  sparkle)  if  it  is  ever 
allowed  to  become  warm  after  once  being  placed  on  ice.  Koumiss 
and  other  fermented  milk  products  must  be  treated  in  a  like 
manner  to  assure  having  them  served  at  their  best. 

Absorption  of  Odors  and  Flavors.  —  Milk,  cream,  and  butter 
are  very  apt  to  absorb  the  flavor  or  odor  from  any  strong  odored 
substance  if  placed  in  the  same  compartment  in  the  ice-box. 
This  is  found  to  be  particularly  objectionable  when  melons, 
cucumbers,  or  onions  are  placed  in  close  proximity  in  the  refrigera- 
tor with  milk,  cream,  or  butter  which  is  not  kept  in  a  receptacle 
closely  covered.  It  is  diflScult  to  avoid  it  in  any  case,  so  that 
the  nurse  is  advised  to  keep  melons,  cucumbers,  etc.,  out  of  the 
ice-box  in  which  the  above-mentioned  products  are  placed. 


THE  SELECTION  AND   CARE   OF  FOOD  35 

Method  of  Washing  Dishes.  —  Cleanliness  must  be  observed 
in  the  care  of  all  food  materials  and  the  utensils  in  which  they  are 
to  be  prepared.  If  the  nurse  will  observe  the  scientific  rules 
governing  the  solubility  of  the  foodstuffs,  she  will  be  able  to 
save  herself  much  time  and  trouble.  For  example,  it  is  a  known 
scientific  fact  that  starch  is  insoluble  in  cold  water  and  more  or 
less  soluble  in  boiling  water,  hence  it  would  be  a  useless  waste  of 
time  to  try  to  wash  a  utensil  in  which  a  starchy  food  has  been 
cooked  in  cold  water.  Fats  solidify  under  the  influence  of  cold 
and  melt  under  the  influence  of  heat,  so  that  hot  water  should  be 
used  in  conjunction  with  soap  or  an  alkali  to  remove  grease  from 
dishes  and  silver  and  utensils.  Albumens  are  soluble  in  cold 
water  and  are  coagulated  in  hot,  therefore  to  remove  milk,  egg 
white,  and  like  protein  substances  from  glasses,  spoons,  etc.,  it  is 
advisable  to  soak  first  in  cold  water  to  wash  out  the  food  material, 
and  then  to  wash  thoroughly  in  hot  soapsuds  to  cleanse  and  polish. 
The  dishcloths  used  in  the  washing  and  drying  of  dishes  and 
kitchen  utensils  should  be  washed  after  using  in  hot  soapsuds, 
rinsed  in  clear  water,  then  dried  in  the  sun.  When  this  is  im- 
possible, they  should  at  least  be  hung  in  the  fresh  air  to  make 
them  sweet  and  clean  before  the  next  using.  In  contagious  diseases 
the  care  of  the  utensils  and  dishes  used  by  the  patient  is  of  the 
utmost  importance.  They  should  be  thoroughly  sterilized  before 
being  placed  with  those  used  by  the  rest  of  the  family,  otherwise 
the  disease  may  be  communicated  to  the  unaffected  members. 
A  word  about  the  handling  of  glasses  and  spoons  used  in  adminis- 
tering medicine  in  the  sick-room :  It  is  advisable  when  possible 
to  keep  these  separate  from  those  used  on  the  tray,  as  many 
medicines  have  a  very  lasting  and  disagreeable  taste,  which  is 
more  than  apt  to  cling  to  the  spoons  or  glasses  in  which  they  are 
measured  and  in  turn  be  communicated  to  the  food,  making  it 
distinctly  unpalatable.  This  has  been  found  to  be  the  case  with 
asafetida,  valerian,  ichthyol,  etc. 

Contamination  of  Food.  —  Food  should  always  be  protected 
from  dirt  and  dust  and  from  contamination  and  pollution  from  flies 
and  other  insects.    Typhoid  fever  and  certain  intestinal  disturb- 


36  DIETETICS  FOR  NURSES 

ances  have  been  known  to  result  from  flies  coming  in  contact  with 
raw  food  —  milk,  for  example.  Poisoning  due  to  polluted  water 
used  to  freshen  vegetables  has  already  been  spoken  of.  All  of 
these  types  of  poisoning  may  be  avoided  by  using  care  in  the 
handling  of  the  fresh  foods.  Ptomaines,  however,  are  not  easy 
to  prevent.  Their  source  cannot  always  be  traced  to  one  partic- 
ular article  of  diet.  They  may  be  present  in  cooked,  raw,  frozen, 
or  canned  foods.  At  times  the  evidence  of  extreme  decomposition 
will  be  found  in  the  foods  themselves,  while  at  other  times  there 
will  be  no  such  evidence  in  the  food,  but  the  result  of  the  ptomaine 
will  be  perfectly  evident  whenever  certain  individuals  partake  of 
that  food.  This  is  a  personal  idiosyncrasy  which  it  is  impossible 
to  account  for. 

Food  Poisoning.  —  Poison  caused  by  decomposed  eggs  has 
manifested  itself  in  individuals  who  have  partaken  of  cake  in  which 
such  eggs  were  used.  Canned  meat  and  fish  have  produced  the 
most  violent  types  of  ptomaine  poisoning.  As  a  rule  in  these 
cases  the  canned  article  has  begun  to  decompose  and  while  the 
decomposition  may  not  have  advanced  sufficiently  far  to  be 
discernible  from  the  flavor  or  odor,  it  is  there,  and  if  the  resistance 
of  the  individual  eating  this  food  is  not  great  serious  danger  may 
result.  Poisoning  develops  in  some  individuals  upon  the  eating 
of  shellfish,  strawberries,  oranges,  pimentos,  and  various  other 
foods,  —  another  evidence  of  personal  idiosyncrasy  against  certain 
articles  of  diet.  There  is  no  way  to  overcome  these  idiosyncrasies ; 
the  only  thing  to  do  is  to  warn  the  individuals  so  affected  to  let 
the  offending  foods  alone. 

ADULTERATION  OF  FOOD 

The  adulteration  of  food,  which  formerly  was  practiced  by  un- 
scrupulous dealers  to  cover  up  inferior  articles,  or  by  manufacturers 
to  prevent  or  arrest  decomposition  in  canned  goods,  is  regulated 
by  law.  The  passage  of  the  National  Pure  Food  and  Drug  Act 
gave  the  Government  authority  to  regulate  the  preservatives 
and  coloring  matter  used  in  canned  and  bottled  goods,  forcing  the 
manufacturers  to  state  on  the  label  the  exact  contents  of  each 


THE  SELECTION  AND   CARE  OF  FOOD  37 

bottle  or  can.  There  are  likewise  stringent  laws  governing  the 
adulteration  of  milk,  butter,  and  other  articles  of  food. 

Tests  for  Adulterants.  —  Boric  acid,  borax,  and  formaldehyde 
are  the  preservatives  more  often  found  in  milk.  These  chemicals 
are  introduced  to  arrest  the  natural  souring  and  decomposition 
which  takes  place  after  milk  reaches  a  certain  age.  Occasionally 
salicylic  acid  and  sodium  carbonate  are  used.  Formaldehyde  may 
be  detected  by  placing  about  20  c.c.  of  milk  in  a  small  glass  vessel 
or  tube.  Dilute  with  an  equal  amount  of  pure  water,  add  com- 
mercial sulphuric  acid,  allowing  it  to  flow  gently  down  the  inside  of 
the  tube.  A  purple  ring  will  appear  at  the  zone  of  contact  if 
formaldehyde  is  present.  "  Boric  acid  and  borax  may  be  detected 
by  adding  a  drop  or  two  of  hydrochloric  acid  to  a  few  drops  of  milk 
in  a  w^hite  dish  and  then  several  drops  of  a  saturated  alcoholic 
solution  of  turmeric.  The  dish  is  then  heated  gently  for  a  few 
minutes,  and,  if  boric  acid  or  borax  is  present,  a  pink  or  dark  red 
color  will  appear.  A  dark  blue-green  should  appear  when  the  dish 
is  cooled  and  a  drop  of  ammonia  added."  ^ 

Canned  goods  must  be  carefully  examined  before  being  used. 
The  domestic  canned  goods  are  rarely  adulterated,  but  imperfect 
sterilization  and  defective  cans  may  bring  about  a  condition  of 
fermentation  and  gas  formation  due  to  bacterial  action.  Cans 
should  have  a  concave  appearance  on  the  top.  If  there  is  a 
bulging  of  the  can  it  may  be  due  to  gas  formation,  and  a  small 
hole  should  be  made  in  the  can  to  note  any  escape  of  this  gas. 
Should  there  be  any  indication  of  fermentation,  the  contents 
should  be  discarded.  It  is  advisable  to  look  with  suspicion  on 
cans  that  appear  old,  rusty,  and  soiled ;  they  are  probably  left- 
over stock  and  liable  to  be  bad.  Peas  which  have  been  imperfectly 
sterilized  produce  a  type  of  gas  which  is  soluble  in  the  liquid. 
After  decomposition  has  occurred  there  will  be  no  apparent 
evidence  by  the  escape  of  gas,  but  the  liquid  will  be  found  to  be 
excessively  acid,  and  will  present  a  muddy  appearance.  Certain 
foreign  importations  of  canned  goods  are  preserved  in  color  by  the 
introduction  of  certain  color  preservatives.     Peas  —  petits  pois, 

1  "Diseases  of  Nutrition  and  Infant  Feeding,"  by  Morse  and  Talbot. 


38  DIETETICS  FOR  NURSES 

for  example  —  and  the  very  small  string  beans  which  are  imported 
are  intensely  green  from  the  copper  sulphate  used.  Its  presence 
may  be  detected  by  adding  a  few  drops  of  hydrochloric  acid 
to  some  of  the  colored  material,  then  dropping  in  a  bright  steel 
nail,  knitting  needle,  or  knife  blade.  There  will  be  a  deposit  of 
copper  salts  (like  copper  plating)  upon  the  steel  if  the  preservative 
is  present  in  the  can.  Canned  corn  is  often  artificially  sweetened 
with  saccharine,  which  may  be  detected  by  shaking  several  table- 
spoonfuls  of  the  liquid  in  an  equal  amount  of  chloroform.  Sac- 
charine is  soluble  in  chloroform,  while  sugar  is  not.  Allow  the 
mixture  to  stand  a  few  minutes  and  remove  some  of  the  chloroform 
which  has  settled  at  the  bottom.  Place  in  a  small  dish,  evaporate 
the  chloroform  by  gently  heating  the  dish ;  taste  the  residue ;  if 
sweet,  saccharine  is  present. 

Coffee  is  adulterated  more  often  when  it  is  put  up  in  ground  or 
powdered  form  than  when  sold  in  the  bean.  Real  coffee  contains 
a  small  percentage  of  oil,  and  will  float  when  thrown  into  a  glass 
of  water.  Substitutes  generally  sink  to  the  bottom.  Coffee 
substitutes  are  often  made  up  of  starch-containing  materials,  such 
as  cereals,  beans,  and  peas.  This  starch  may  be  detected  by 
mixing  one  tablespoonful  of  the  suspected  coffee  in  a  little  cold 
water,  adding  one  cup  of  boiling  water;  allow  it  to  boil  two 
minutes,  filter  through  cotton,  and  pass  the  liquid  through  char- 
coal to  remove  the  color.  When  it  is  cold,  add  a  few  drops  of  dilute 
iodine  solution.     If  starch  is  present,  a  blue  color  will  appear. 

METHODS    USED   IN  THE    PREPARATION    OF    FOOD 

Food  is  prepared  for  consumption  by  a  number  of  methods 
and  the  method  by  which  the  food  is  prepared  either  increases 
or  decreases  its  digestibility,  palatability,  and  general  usefulness. 

Certain  foods,  as  has  already  been  stated,  require  a  high  degree 
of  temperature  to  make  them  wholesome,  but  if  this  temperature 
is  applied  by  means  of  heated  fat,  as  in  frying,  the  food  is  changed 
from  a  wholesome  to  a  more  or  less  indigestible  article.  In  health 
the  organs  of  digestion  are  capable  of  overcoming  much  of  the  harm 
wrought  by  wrong  preparation,  but  even  in  the  healthy,  normal 


THE  SELECTION  AND  CARE  OF  FOOD  39 

individual  a  steady  diet  of  fried  food  will  eventually  undermine 
what  is  known  as  good  digestion.  In  abnormal  conditions  (ill- 
ness) frying  is  a  method  seldom,  if  ever,  used. 

Preparation  of  Food.  —  The  various  methods  to  which  food  is 
subjected  in  preparation  for  human  consumption  may  be  summed 
up  as  follows :  boiling,  simmering,  steaming,  baking,  roasting, 
broiling,  frying,  sautling. 

Boiling  is  cooking  in  water  raised  to  the  boiling  point,  212°  F. 
(sterilizing).  This  method  is  commonly  used  in  the  cooking  of 
starchy  vegetables  and  cereals,  and  in  the  cooking  of  green  vege- 
tables, such  as  spinach,  carrots,  beets,  corn,  asparagus,  etc. 
Stewing  is  a  form  of  boiling.  As  a  rule  water  is  used,  and  the  vessel 
is  left  uncovered,  so  that  as  the  food  is  cooked  the  surplus  moisture 
evaporates,  leaving  the  food  tender.  Dried  fruits,  such  as  prunes 
and  apricots,  are  prepared  by  this  method. 

Simmering  is  cooking  in  water,  the  temperature  of  which  is  not 
raised  to  the  boiling  point,  but  kept  between  200°  F.  and  210°  F. 
This  method  is  used  in  the  preparation  of  eggs  and  dishes  in  which 
eggs  predominate,  since  proteins  are  made  tough  if  subjected  to  a 
high  degree  of  temperature.  Coddled  eggs,  for  example,  are  pre- 
pared by  placing  the  egg  in  a  clean  vessel  and  pouring  over  it  the 
boiling  water,  then  covering  the  vessel  and  allowing  it  to  stand 
for  ten  or  fifteen  minutes.  The  vessel  and  the  cold  egg  reduce  the 
temperature  of  the  water  to  about  185°  or  190°  F.  and  in  this  way 
prevent  a  toughening  of  the  albumen  of  which  eggs  are  chiefly 
composed.  Soups,  broths,  ragouts,  etc.,  are  prepared  by  this 
method. 

Steaming  is  cooking  over  hot  water  or  by  steam.  This  method 
may  be  accomplished  on  the  top  of  the  stove  in  a  "  double  boiler  " 
or  in  the  oven  in  a  deep  covered  pan  fitted  with  a  "  rack  "  to  hold 
the  article  to  be  cooked.  Either  method  allows  the  vessel 
in  which  the  food  is  placed  to  be  surrounded  by  boiling  water,  but 
does  not  insure  suflficient  heat  to  raise  the  food  within  to  the  boiling 
point. 

Baking  and  roasting  are  both  brought  about  in  the  oven.  Bread, 
biscuits,  pies  and  other  pastry,  potatoes,  cakes,  etc.,  are  baked. 


40  DIETETICS  FOR  NURSES 

while  meats,  roast  of  beef,  lamb,  veal,  mutton,  as  well  as  chicken, 
turkey,  duck,  and  large  fish  are  roasted.  The  heat  in  the  oven  may 
be  intense.  The  outside  or  cut  surface  of  the  meat  is  seared,  the 
soluble  albumens  are  coagulated,  thus  sealing  the  juices  within. 
If  the  meat  is  placed  in  a  pan  surrounded  by  cold  water  and  then 
placed  in  the  oven,  the  juices  are  "  drawn  out  "  in  the  water. 
These  juices  contain  the  flavoring  matter  or  extractives.  Meat 
so  treated  is  not  so  palatable  or  highly  flavored  as  that  which  has 
first  been  subjected  to  intense  heat,  the  water  for  the  gravy  added 
later. 

Frying  and  sauteing  is  cooking  in  hot  fat.  Food  may  be 
fried  in  deep  fat,  as  is  demonstrated  in  the  cooking  of  croquettes, 
doughnuts,  etc.,  or  it  may  be  sauted  in  butter  or  oil  in  a  shallow 
frying  pan  or  griddle.  The  latter  method  is  used  in  making  hashed 
brown  potatoes,  for  example ;  also  in  the  frying  of  griddle  cakes, 
etc. 

Broiling.  —  In  broiling  or  grilling  the  article  to  be  cooked  is 
exposed  to  direct  heat,  either  to  the  blaze  or  to  a  very  hot  surface. 
The  result  is  the  same  as  in  roasting.  The  outer  surface  is  seared, 
sealing  the  juices  within.  Meat  to  be  broiled  is  generally  cut 
thinner  than  that  to  be  roasted.  The  article,  whether  it  is  meat 
(steak),  chops,  birds,  or  chicken,  is  placed  about  three  inches  away 
from  the  flames  and  turned  frequently  until  the  surfaces  are 
seared,  after  which  the  article  is  placed  in  a  cooler  part  of  the  stove 
to  allow  the  interior  to  be  cooked.  Pan  broiling  is  done  on  top  of 
the  stove.  The  article  to  be  broiled  is  placed  directly  upon  a  very 
hot  surface,  there  is  no  grease  used  and  the  meat  must  be  turned 
frequently  to  prevent  burning. 

Poaching.  —  This  term  is  applied  chiefly  to  the  cooking  of  eggs 
in  a  shallow  pan  of  water  heated  just  below  the  boiling  point.  To 
be  properly  poached  an  egg  must  be  perfectly  fresh,  or  the  white 
and  yolks  will  run  together  and  present  an  unappetizing,  un- 
palatable appearance. 

The  following  time-table  should  be  used  in  the  preparation  of 
food  to  insure  correct  cooking : 


THE  SELECTION  AND  CARE   OF  FOOD 


41 


TIME-TABLE 


Material 


Method 


Time 


Beef  (fresh) 

Corned  beef 

Shoulder  or  leg  of  mutton      .     .     .     . 

Shoulder  or  leg  of  lamb 

Fowl  (4  to  5  pounds) 

Chicken  (3  lb.  hen) 

Ham 

Lobster 

Salmon  (whole) 

Vegetables : 

Asparagus 

String  beans 

Dried  beans 

Beets  (new) 

Beets  (old) 

Beet  greens 

Brussels  sprouts 

Cabbage  (for  creamed  cabbage)  .     . 

Cabbage       

Cauliflower 

Celery 

Corn  (green) 

Onions 

Oyster  plant  (salsify) 

Parsnips 

Peas 

Carrots 

Potatoes  (white) 

Potatoes  (sweet) 

Rice 

Squash 

Spinach 

Tomatoes  (stewed) 

Turnips 

Coffee 

Beef  (ribs  or  loin,  rare)  per  pound  ,  . 
Beef  Cribs  or  loin,  well  done)  per  pound 
Beef  (rolled,  rare)  per  pound  .  .  . 
Beef  (rolled,  well  done)  per  pound  .     . 

Leg  of  lamb  per  pound 

Leg  of  mutton,  per  pound  .... 
Mutton     (stuffed,     forequarter)      per 

pound  

Lamb,  well  done,  per  pound  .... 
Veal,  well  done,  per  pound     .... 


Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 

Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Boiled 
Roasted 
Roasted 
Roasted 
Roasted 
Roasted 
Roasted 

Roasted 
Roasted 
Roasted 


4  to  6  hours 
4  to  7  hours 

3  to  5  hours 
2  to  3  hours 
2  to  4  hours 

1  to  1^  hours 

4  to  6  hours 

25  to  30  minutes 
10  to  15  minutes 

25  to  30  minutes 

1  to  2  hours 

1  to  2  hours 
45  minutes  to  1  hour 

4  to  6  hours 

1  hour  or  more 
15  to  20  minutes 
10  to  15  minutes 
30  to  80  minutes 

1  to  1^  hours 

2  to  2|  hours 
10  to  20  minutes 

45  minutes  to  2  hours 
45  minutes  to  1  hour 
30  to  45  minutes 
20  to  60  minutes 
20  to  40  minutes 
20  to  35  minutes 
20  to  30  minutes 
20  to  30  minutes 
20  to  30  minutes 
15  to  20  minutes 
20  to  30  minutes 
45  to  60  minutes 

3  to    5  minutes 
8  to  10  minutes 

12  to  15  minutes 
12  to  15  minutes 
15  to  20  minutes 
10  minutes 
15  minutes 

15  to  20  minutes 
15  to  18  minutes 
20  to  25  minutes 


42 


DIETETICS  FOR  NURSES 
TIME-TABLE  —  Continued 


Material 


Pork,  well  done,  per  pound  .  .  . 
Chicken,  well  done,  per  pound  .  . 
Turkey  (8  to  10  pounds)    ,     .     .     . 

Ducks  (domestic) 

Ducks  (wild) 

Small  birds 

Large  fish 

Fish  steaks,  stuffed 

Steak,  1  inch  thick 

Steak,  If  inches  to  2  inches  thick  . 
Lamb  chop  or  mutton  chop   .     .     . 

Quail 

Squab     

Spring  chicken  (broiler)     .     .     .     . 

Shad 

Bluefish 

Bread  (loaf) 

Rolls  (risen) 

Biscuits , .     .     .     . 

Muffins 

Sponge  cake  (loaf) 

Layer  cake 

Cooldes 

Custards 

Steamed  brown  bread 

Pastry 

Potatoes 

Scalloped  dishes 

Steamed  puddings 

Plum  pudding 


Method 


Time 


Roasted 

20  minutes 

Roasted 

15  to  20  minutes 

Roasted 

3  hours 

Roasted 

1  to  If  hours 

Roasted 

20  to  30  minutes 

Roasted 

15  to  30  minutes 

Roasted 

45  minutes  to  1  hour 

Roasted 

45  minutes  to  1  hour 

Broiled 

6  to  12  minutes 

Broiled 

15  to  20  minutes 

Broiled 

10  to  15  minutes 

Broiled 

12  to  20  minutes 

Broiled 

12  to  20  minutes 

Broiled 

20  to  40  minutes 

Broiled 

12  to  15  minutes 

Broiled 

12  to  15  minutes 

Baked 

45  minutes  to  1  hour 

Baked 

20  to  25  minutes 

Baked 

10  to  12  minutes 

Baked 

20  to  25  minutes 

Baked 

45  to  60  minutes 

Baked 

20  to  25  minutes 

Baked 

10  to  15  minutes 

Baked 

20  to  60  minutes 

Steamed 

2  to  3  hours 

Baked 

30  to  45  minutes 

Baked 

30  minutes  to  1  hour 

Baked 

20  minutes 

Baked 

1  to  4  hours 

Baked 

2  hours  (after  steam- 

ing 10  hours) 

CAEE   OF  ICE-BOX  AND   CONTENTS 

The  ice-box  plays  an  important  role  in  the  preservation  of  the 
health  and  comfort  of  the  family,  as  well  as  that  of  the  invalid. 
Therefore  the  first  consideration  is  the  cleanliness  of  it.  The 
old-fashioned  boxes  were  constructed  without  ventilation.  This 
was  clearly  a  mistake,  since  many  foods  absorb  both  the  odor  and 
flavor  of  the  substances  about  them  if  allowed  to  stand  for  any 
great  length  of  time  in  a  closed  compartment  with  them.  The 
ice-boxes  or  refrigerators  of  to-day  have  a  ventilation  system  which 


THE  SELECTION  AND  CARE  OF  FOOD     43 

insures  a  circulation  of  air  constantly  throughout  the  interior  of 
the  box.  The  drain  pipes  require  special  attention,  because  no 
matter  how  clean  the  box  itself  is  kept,  the  melting  of  the  ice 
causes  a  slime  to  accumulate  on  the  inside  of  the  pipe  which  will 
clog  it  and  become  offensive  unless  it  is  flushed  out  often.  This 
may  be  accomplished  by  pouring  through  it  a  solution  made  by 
dissolving  one- half  ounce  of  borax,  washing  soda,  or  ammonia  in 
one  gallon  of  boiling  water.  The  adjustable  part  of  the  pipe  can 
be  removed  and  cleaned  with  a  long  brush  made  for  the  purpose. 
The  pipe  is  then  replaced  and  the  boiling  water  poured  through. 
In  this  way  the  entire  drainage  system  of  the  box  is  completely 
cleaned.  All  loose  bits  of  food  which  may  drop  from  the  con- 
tainers to  the  floor  and  shelves  should  be  carefully  removed 
each  day  and  the  interior  of  the  box  and  shelves  thoroughly  wiped 
out.  Three  times  a  week  is  sufficient  to  wash  and  flush  the  box 
and  pipes  unless  milk,  cream,  or  other  food  materials  have  been 
spilled,  in  which  case  it  should  be  washed  at  once  before  it  has  an 
opportunity  to  sour  or  spoil  and  become  offensive.  Ice  should 
always  be  washed  off  before  being  put  in  the  box,  and  all  milk  and 
cream  bottles  should  likewise  be  wiped  with  a  clean  wet  cloth  before 
being  placed  on  the  ice. 

Hot  food  must  never  be  put  in  the  ice-box,  as  the  heat  from  the 
food  will  raise  the  temperature  of  the  air  in  it.  In  some  cases 
the  sudden  chilling  of  the  food  itself  is  undesirable,  but  this  is  not 
so  often  the  case.  However,  the  best  results  are  obtained  by  first 
allowing  the  food  to  cool,  and  then  placing  it  on  ice.  This  is 
particularly  the  case  with  jellies  made  from  gelatine. 

SUMMARY 

To  summarize  the  points  affecting  care  and  preparation  of  the 
foods  constituting  any  dietary,  we  may  say  that  cleanliness  is 
the  keynote  of  the  situation.  No  food  is  wholesome  unless  it  is 
clean ;  no  dietary  is  permissible  if  prepared  without  due  regard 
to  this  principle. 

Substitution  in  Cooking.  —  Substitution  is  another  point 
requiring  knowledge  and  attention,  and  the  nurse  who  is  able  to 


44  DIETETICS  FOR  NURSES 

successfully  substitute  a  food  of  equal  value  and  similar  composition 
for  one  which  will  distress  or  is  disliked  by  the  patient,  or  one  which 
is  unobtainable,  has  gone  far  toward  attaining  efficiency  in  the 
practical  use  of  dietetics. 

Formulation  of  Diets.  —  A  word  as  to  the  formulation  of  diets  : 
Let  it  be  understood  that  the  diet  plays  just  as  important  a  part 
in  the  treatment  of  many  pathological  conditions  as  the  medicinal 
treatment.  In  many  cases  it  is  the  chief  point  upon  which  the 
life  of  the  patient  depends.  Let  it  be  understood,  then,  that  all 
dietaries  should  be  ordered  by  the  physician,  and  no  nurse  should 
undertake  to  formulate  a  dietary  for  the  patient  unless  permitted 
to  do  so  by  the  physician  in  charge,  or  unless  there  is  no  physician 
to  do  it  for  her. 

THE  TRAY 

As  the  patient's  tray  assumes  an  important  part  of  the  daily 
regime,  it  is  necessary  to  give  close  attention  to  the  arrangement 
and  serving  of  it.  There  are  certain  definite  rules  to  observe : 
(1)  The  linen,  silver,  glassware,  china,  and  food  must  be  absolutely 
clean.  (2)  The  tray  must  be  sufficiently  large  not  to  appear 
crowded.  (3)  The  arrangement  of  the  obligatory  articles,  such  as 
salt  and  pepper,  silver,  water  glass,  napkin,  etc.,  must  be  alike 
at  every  meal ;  this  not  only  facilitates  the  service  by  making  it 
easy  for  the  nurse  to  see  whether  any  of  these  necessary  articles 
are  left  off,  but  it  also  enables  the  patient  to  find  them  without 
trouble. 

The  Linen.  —  The  linen  cover  of  the  tray  must  be  clean  and  un- 
creased.  The  napkin  likewise  must  be  clean  and  unwrinkled. 
The  china  must  be  free  from  chips  and  cracks.  Care  must  be 
taken  not  to  put  a  collection  of  odd  pieces  on  the  tray  as  it  gives 
an  untidy  appearance. 

The  Silver.  —  The  silver  must  be  bright  and  in  cold  weather 
made  slightly  warm,  as  must  also  the  china.  The  chill  of  cold 
silver  may  readily  obliterate  a  fragile  appetite,  and  to  place  hot 
food  in  cold  dishes  will  deprive  it  of  much  of  its  palatability.  The 
foods  intended  to  be  hot  must  be  really  hot,  not  warm,  and  those 


THE  SELECTION  AND  CARE  OF  FOOD  45 

which  are  intended  to  be  cold  should  be  thoroughly  chilled  before 
being  served  to  a  patient.  The  placing  of  flowers  on  a  tray  is 
a  questionable  addition  to  it ;  a  single  flower  laid  across  the  folded 
napkin  may  add  daintiness  and  attractiveness,  but  it  is  poor 
judgment  to  over-decorate,  either  with  flowers  or  by  garnishing 
the  dishes. 

Arranging  the  Tray.  —  If  the  nurse  will  place  the  necessary 
articles  upon  the  tray  and  memorize  their  position  so  that  she  will 
be  able  to  duplicate  the  same  at  each  meal,  she  will  be  able  to  tell 
at  a  glance  if  everything  needed  is  in  its  proper  place,  thereby 
saving  herself  unnecessary  steps  and  the  patient  the  worry  of 
having  to  wait  until  they  can  be  brought.  Food  should  not  be 
allowed  to  stand  in  the  sick-room,  and  glasses  or  plates  in  which 
food  has  been  served  should  be  removed  from  sight  as  soon  as  the 
patient  finishes  with  them.  Care  must  be  taken,  however,  not 
to  create  the  impression  of  hurry  or  the  patient  will  be  made 
nervous  and  either  will  lose  her  appetite  or  have  indigestion. 

The  nurse  should  be  careful  of  her  topics  of  conversation  during 
the  meal  hour.  Especially  must  disagreeable  subjects  and  busi- 
ness matters  be  rigidly  excluded  if  the  invalid  is  to  obtain  the  full 
benefit  of  the  food  served  her. 

In  the  cases  requiring  special  diets,  the  nurse  should  make  out 
the  "  diet  sheet  "  for  the  day.  In  hospitals  this  is  passed  to  the 
dietitian,  who  carries  out  the  directions  laid  down  by  the  physician. 
The  nurse,  however,  should  carefully  check  the  tray  before  serving 
it,  since  mistakes  sometimes  occur,  and  to  give  the  wrong  food 
to  a  patient  suffering  from  certain  disorders  may  give  rise  to  serious 
trouble,  causing  pain  and  discomfort  and  at  times  death. 


CHAPTER   III 
THE  FUEL  VALUE  OF  FOOD 

Science  has  proved  that  the  human  body  is  composed  of  certain 
chemical  elements  and  that  food  materials  are  combinations  of 
like  elements ;  it  has  likewise  proved  that  the  body  will  utilize  her 
own  structure  for  fuel  to  carry  on  the  work  of  her  various  functions 
unless  material  is  supplied  for  this  purpose  from  an  outside  source^ 
namely,  food,  which  in  chemical  composition  so  closely  resembles 
that  of  the  human  body. 

Amount  and  Type  of  Food.  —  The  next  point  of  investigation 
would  logically  be  the  amount  and  kind  of  food  necessary  to  best 
accomplish  this  purpose.  To  be  able  to  do  this  it  was  necessary 
to  have  some  standard  unit  by  which  to  measure  the  amount 
of  heat  each  food  was  capable  of  producing  when  burned  outside 
the  body,  after  which  it  was  more  or  less  simple  to  calculate 
the  heat  production  of  each  of  the  food  combinations  within  the 
organism.  An  apparatus  known  as  the  "  Bomb  Calorimeter  "  ^ 
was  devised  by  Berthelot,  and  adapted  for  the  examination  of  food 
materials  by  Atwater  and  Blakesley.  The  food  material  to  be 
tested  was  placed  within  the  bomb,  which  was  charged  with  a 
known  amount  of  pure  oxygen.  The  bomb  was  then  sealed  and 
immersed  in  a  weighed  amount  of  pure  water,  into  w^hich  a  very 
delicate  thermometer  was  inserted.  The  food  within  the  bomb 
was  ignited  by  means  of  an  electric  fuse,  and  the  heat  given  off  by 
the  burning  of  the  material  was  communicated  to  the  surrounding 
water  and  was  registered  upon  the  thermometer.  It  was  evident 
that  some  definite  name  had  to  be  devised  by  which  these  heat 
units  might  be  known.  Hence  the  name  "  calorie,"  which  rep- 
resents the  amount  of  heat  required  to  raise  the  temperature  of  1 

1  For  full  description  and  methods  used,  see  "Journal  of  The  American  Chemical 
Society,"  July,  1903. 

46 


THE  FUEL  VALUE  OF  FOOD         47 

kilogram  of  pure  water  1  degree  centigrade,  or  about  4  pounds  of 
water  2  degrees  Fahrenheit. 

Transformation  of  Foods  into  Available  Fuel.  —  A  comparison 
has  been  made  between  the  human  body  and  a  steam  engine,  but 
this  comparison  is  not  adequate,  since  the  food  does  not  produce 
heat  within  the  body  originally,  but  energy  of  which  heat  is  a  by- 
product. Each  food  combination  has  a  certain  amount  of  dormant 
energy  within  its  structure  and  this  energy  does  not  become 
active  nor  can  it  be  utilized  by  the  body  until  the  food,  of  which  it 
is  a  part,  is  changed  within  the  organism  to  substances  more 
nearly  like  its  own.  This  liberated  active  energy  is  then  used  as 
a  motive  power  to  carry  on  the  internal  and  external  work  of  the 
body,  and  the  heat,  which  is  invariably  the  consequence  of  any 
active  energy  (motion),  leaves  the  body  as  such.  It  will  be  seen, 
then,  that  the  human  body  acts  not  as  a  steam  engine,  but  rather 
as  a  transforming  machine  by  means  of  which  the  dormant  energy 
of  the  food  is  transformed  into  an  active  agent  of  which  heat  is  a 
natural  result. 

In  the  calorimeter  it  was  found  that  the  carbohydrates  and  fats 
burned  to  the  same  end  products,  namely,  carbon  dioxide  and 
water,  while  the  proteins,  upon  oxidation,  produced  carbon  diox- 
ide, water,  and  nitrogen  gas.  In  the  body  it  was  found  that  the 
carbohydrates  and  the  fats  acted  in  exactly  the  same  manner  as 
in  the  calorimeter,  producing  the  same  end  products.  But  this 
was  not  the  case  with  the  proteins ;  the  oxidation  process  of  this 
chemical  combination  was  found  to  be  not  nearly  so  complete 
within  the  body  as  in  the  calorimeter,  and  instead  of  the  free  oxygen 
as  produced  in  the  apparatus  there  was  urea  and  other  nitrogenous 
substances  eliminated  which,  while  combustible,  represented  a 
less  complete  oxidation  of  the  proteins. 

The  following  table  shows  the  average  heats  of  combustion : 

TABLE  2  VII 

Carbohydrates 4.1    cal.  per  gram 

Fats  9.45  cal.  per  gram 

Protein  (nitrogen  X  6.25)         ....     5.95  cal.  per  gram 

2  "Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


48  DIETETICS  FOR  NURSES 

The  loss  of  potential  energy  due  to  the  incomplete  oxidation 
of  the  proteins  in  the  body  is  approximately  1.2  calories  to  each 
gram  of  protein  in  food,  and  in  calculating  the  fuel  value  of  any 
food  in  the  body  due  allowance  must  be  made  for  the  losses  in 
digestion.  It  has  been  found  advisable  to  calculate  these  losses 
in  a  general  way,  using  a  mixed  diet  as  a  basis  upon  which  they  are 
formed.  The  following  table  shows  an  approximate  average  of 
these  losses  due  to  incomplete  digestion :  ^ 

TABLE   VIII 


Lost 

Absorbed 

Carbohydrates 

Fats 

Proteins 

2  per  cent 
5  per  cent 
8  per  cent 

98  per  cent 
95  per  cent 
92  per  cent 

Rubner's  calculations  on  the  fuel  value  of  foods  are  slightly 
higher  than  the  ones  upon  which  the  diets  in  this  book  are  based. 
This  is  due  to  the  fact  that  he  made  his  experiments  upon  dogs  in- 
stead of  the  human  being,  and  the  averages  due  to  losses  in  digestion 
are  not  so  great,  as  the  table  will  show : 

RUBNER'S   TABLE  3   IX 

Carbohydrates 4.1  calories  per  gram 

Fats 9.3  calories  per  gram 

Proteins 4.1  calories  per  gram 

Table  of  approximate  physiological  fuel  value  of  the  food  con- 
stituents :  ^ 

TABLE   X3 

Carbohydrates 4.1     x  98%  =  4  cal.  per  gram 

Fats 9.45  X  95%  =  9  cal.  per  gram 

Proteins 4.35  X  92%  =  4  cal.  per  gram 

EFFECT  OF  HEAT  AND  COLD  UPON  THE  FOODSTUFFS 

In  primeval  days,  when  man  led  a  more  natural  life,  his  very 
existence  depended  upon  his  ability  to  WTCst  from  the  earth  his 

'  "Chemistry  of  Food  and  Nutrition,"  by  Sherman. 


THE  FUEL  VALUE  OF  FOOD  49 

means  of  livelihood.  As  physical  strength  was  the  first  item  of 
importance,  he  took  by  force  what  he  needed  to  make  him  strong, 
and  the  efforts  thus  made  added  strength  and  endurance  to  his 
physical  being. 

Factors  Affecting  the  Preparation  of  Food.  —  This  necessary 
fight  for  life  made  it  impossible,  even  had  he  known  or  desired  to 
have  things  otherwise,  for  him  to  waste  time  upon  additional 
preparation  of  the  food ;  he  took  it  as  it  came  in  its  raw  state  and 
thrived  upon  it.  To-day,  however,  everything  has  changed  — 
instead  of  living  and  working  out  of  doors  and  deriving  the  benefits 
nature  places  before  us,  we  are  crowded  into  small  spaces,  lacking 
both  air  and  sunshine ;  we  work  less  with  our  hands  and  more 
with  our  brains ;  we  put  a  strain  upon  the  nervous  system,  which 
in  turn  requires  additional  care  on  the  part  of  the  individual  to 
prevent  a  general  disintegration  of  the  organism.  Altogether  it  is 
a  question  of  how  to  increase  the  output  of  energy  without  a 
complete  demolition  of  the  human  machine,  and  this  we  must  do 
by  giving  careful  attention  to  the  materials  used  for  the  purpose  of 
building  and  repairing  the  body  and  that  utilized  by  the  body  as 
fuel,  so  that  a  maximum  value  may  be  obtained  with  a  minimum 
amount  of  effort  on  the  part  of  the  organism. 

It  has  been  proved  that  the  body  does  not  use  the  materials  in 
the  form  in  which  they  are  eaten ;  their  nature  is  too  complex  for 
it  to  handle.  Therefore  the  food  passes  through  a  series  of  changes, 
chemical  in  character,  made  ready  to  replace  the  material  which 
has  been  used  in  carrying  on  the  internal  and  external  work  of  the 
body. 

Effect  of  Cooking  upon  Food.  —  It  has  been  proved  that  the 
diet  of  man  can  be  made  more  effective  for  his  needs  if  the  raw 
materials  are  prepared  before  they  are  eaten.  This  preparation 
of  food  is  known  as  cooking.  Food  is  cooked,  then,  for  certain 
definite  reasons,  namely:  (1)  to  increase  its  digestibility;  (2)  to 
destroy  the  parasites  and  harmful  bacteria  which  may  infect  it ; 
and  (3)  to  stimulate  the  appetite  by  developing  its  flavor  and 
appearance.  It  will  be  seen  at  a  glance  that  a  knowledge  of  the 
effect  of  heat,  and  to  a  less  extent  cold,  upon  the  foodstuffs  is 


50  DIETETICS  FOR  NURSES 

not  only  important  but  very  essential,  since  it  comes  within  the 
province  of  the  nurse  to  protect  her  patient  from  all  harmful  in- 
fluences which  may  jeopardize  his  recovery. 

Effect  of  Cold  upon  Food.  —  The  effect  of  cold  upon  the  various 
foodstuffs  has  not  been  so  thoroughly  investigated  as  the  effect 
of  heat.  Little  is  actually  known  of  the  chemical  changes  which 
are  directly  due  to  the  influence  of  a  lowered  temperature  upon 
food  materials.  Certain  investigators  have  been  working  upon 
milk,  and  have  proved  that  some  of  the  bacteria  infecting  milk 
may  disappear  while  it  is  frozen,  while  others  increase  rapidly, 
especially  in  raw  milk.  These  investigations  have  only  been 
made  with  milk  frozen  for  several  days.  There  is  no  information 
on  the  chemical  changes  taking  place  in  milk  frozen  only  twenty- 
four  hours.  Rosenau  ^  states  that  he  found  that  freezing  milk 
for  forty-eight  hours  did  not  prevent  the  growth  of  t}^hoid 
bacilli,  but  did  destroy  the  lactic  acid  bacilli. 

Without  a  doubt  the  application  of  cold  to  certain  foods  has  its 
advantages  in  certain  conditions.  Many  beverages  valuable  as 
nutrients  are  made  unpalatable  if  served  warm,  whereas  they  not 
only  serve  as  foods  but  allay  thirst  and  in  some  cases  relieve 
nausea  when  they  are  chilled  to  the  desired  temperature.  Possibly 
the  partaking  of  large  quantities  of  excessively  cold  food  will  in- 
fluence the  rate  of  digestion  in  the  stomach,  since  the  food  mass 
must  be  of  the  temperature  of  the  blood  before  digestion  begins. 
However,  since  there  is  a  large  amount  of  blood  constantly  circu- 
lating around  the  stomach,  especially  during  the  period  of  diges- 
tion, it  is  a  question  as  to  whether  a  reasonable  amount  of  iced 
food  would  make  a  great  deal  of  difference.  It  would  be  unwise 
to  risk  feeding  large  quantities  of  very  cold  food  or  very  hot  food 
to  individuals  who  are  abnormal  in  health,  as  serious  conditions 
have  been  observed  to  result  from  an  injudicious  use  of  both. 

Effect  of  Heat  upon  Starch.  —  Dry  Heat :  The  effect  of  dry  heat 
upon  starch  is  to  convert  it  into  dextrin.  A  temperature  ranging 
from  300°  F.  to  400°  F.,  applied  to  a  starchy  food,  brings  about 
this  chemical  change  in  less  time  than  is  accomplished  by  applying 

*  Kosenau :  Hygienic  Laboratory,  Bulletin  No.  6,  Washington,  1909. 


THE  FUEL  VALUE  OF  FOOD         51 

a  lesser  degree,  212°  F.,  for  example.  The  best  example  of  this 
change  from  starch  to  dextrin  is  seen  in  some  of  the  proprietary 
infant  foods.  It  is  also  seen  in  well-made  toast ;  when  that  article 
of  food  is  browned  thoroughly  the  change  has  gone  further ;  when 
it  is  burned  the  starch  has  been  carbonized. 

Starch  is  changed  from  an  insoluble  substance  to  a  more  soluble 
one  in  the  presence  of  moisture  and  a  temperature  of  212°  F.  A 
long-continued  boiling  dextrinizes  the  starch,  making  it  more 
readily  handled  by  the  digestive  apparatus.  The  cooking  of 
vegetables  and  fruit  containing  sugar  and  other  carbohydrates 
tends  to  increase  their  digestibility,  inasmuch  as  some  of  the 
chemical  changes  necessary  for  a  complete  utilization  by  the 
body  are  started  on  the  outside  before  the  food  reaches  the  digestive 
apparatus,  thus  eliminating  some  of  the  work  of  the  organism  which 
is  obligatory  under  other  conditions. 

Heat  likewise  acts  mechanically  upon  starchy  vegetables  in  the 
presence  of  moisture.  The  foods  containing  starch  also  contain 
another  form  of  carbohydrate  not  so  easily  handled  by  the  body  in 
digestion.  This  carbohydrate,  known  as  cellulose,  is  woody  and 
fibrous  in  nature  and  forms  the  skeleton  of  plants,  inclosing  the 
starch  grains  between  its  tenacious  walls.  This  material  delays 
the  digestion  of  the  starch  unless  it  is  softened  and  in  a  measure 
broken  down  before  it  is  allowed  to  come  in  contact  with  the 
enzymes  of  the  digestive  juices.  Thus  the  cooking  of  foods  high 
in  cellulose  is  the  best  means  of  hastening  and  promoting  their 
utilization  in  the  body. 

The  Effect  of  Heat  upon  Fats.  —  As  fats  are  more  digestible 
cold  than  hot,  the  cooking  of  food  in  fat  is  not  desirable  from  a 
health  standpoint.  Fat  is  readily  decomposed  under  the  action 
of  heat,  splitting  to  fatty  acids  and  glycerine.  Since  fatty  acids 
are  irritating  in  character  it  is  not  wise  to  bring  about  the  change 
outside  the  body  where  there  are  no  secretions  to  counteract  their 
irritating  effect  upon  the  mucous  lining  of  the  stomach.  When 
foods  are  fried,  the  fats  surround  the  other  food  materials,  forming 
a  coating  which  causes  them  to  require  a  much  longer  time  for 
leaving  the  stomach  than  they  would  require  if  they  were  not  so 


52  DIETETICS  FOR  NURSES 

treated.  According  to  Cannon,  fats  leave  the  stomach  more 
slowly  than  either  of  the  other  two  foodstuffs,  and  when  the  car- 
bohydrates or  proteins  are  mixed  with  fat  the  delay  in  their 
passage  from  the  stomach  is  greater  than  if  either  were  fed  alone. 
Consequently,  it  is  clearly  demonstrated  that  in  frying  a  food 
(subjecting  it  to  heat  in  the  presence  of  fat)  one  is  courting  disaster 
from  the  point  of  digestion. 

The  Effect  of  Heat  upon  Protein.  —  There  are  a  number  of 
protein  foods,  as  has  already  been  stated,  and  the  care  with  which 
these  foods  are  prepared  either  increases  or  decreases  their  useful- 
ness in  nutrition.  Albumens  are  soluble  proteins,  readily  affected 
by  a  rise  of  temperature  and  decreasing  in  digestibility  in  proportion 
to  the  elevation  of  temperature.  Coagulation  begins  in  the  soluble 
albumens  at  about  135°  F.  This  coagulation  continues,  changing 
the  character  of  the  substance  from  a  soluble  to  an  insoluble  one 
as  the  temperature  rises.  If  the  albumen  is  kept  at  a  temperature 
of  212°  F.  for  a  long  period,  it  will  assume  a  tough,  fibrous  texture, 
difficult  of  digestion  unless  it  is  ground  very  finely  and  masticated 
thoroughly.  The  best  example  of  this  point  may  be  had  in  the 
cooking  of  eggs.  The  white  of  eggs  is  composed  chiefly  of  soluble 
albumen.  If  the  egg  is  placed  in  water  and  the  temperature 
gradually  elevated,  a  change  is  brought  about;  the  character  of 
the  albumen  changes  from  a  sticky  viscid  mass,  first  to  a  jelly-like 
consistency,  somewhat  opalescent  in  looks  and  very  easy  of  diges- 
tion, then  to  one  more  firm  and  more  opaque  but  still  easily 
handled  by  the  digestive  juices.  When  the  temperature  is  kept 
at  the  boiling  point  for  any  length  of  time  the  egg  white  becomes 
tough.  This  toughness  increases  until  a  rubber-like  substance 
is  formed  which  is  more  or  less  difficult  of  digestion. 

The  raw  surfaces  of  meat  —  that  is,  meat  which  has  been  cut  in 
cross  sections  —  have  a  certain  amount  of  soluble  albumen 
brought  to  the  surface  on  account  of  having  the  membranes  which 
inclose  the  sheaths  of  muscle  and  the  blood  cells  severed.  This 
soluble  albumen  is  very  susceptible  to  coagulation.  On  being 
brought  into  contact  with  a  hot  surface,  as  in  broiling  or  roasting, 
this  albumen  coagulates  and  forms  an  effectual  coating  to  the 


THE  FUEL  VALUE  OF  FOOD 


53 


inner  protein,  thus  preventing  an  excess  of  heat  reaching  it  and 
making  it  more  digestible.  This  mode  of  cooking  also  prevents 
the  escape  of  the  soluble  extractives,  thus  making  the  meat  more 
savory  to  the  taste. 

SUMMARY 

In  summing  up  the  effect  of  heat  upon  foodstuffs  as  practiced 

in  cooking,  it  is  seen  that  while  it  undoubtedly  increases  the 

digestibility,  hence  the  usefulness,  of  some  food  materials,  it  also 

decreases  it  in  others.     It  is  important,  then,  for  the  nurse  to 

understand  which  foodstuff  predominates  in  the  material  she  is 

intending  to  use  in  the  diet  of  her  patient,  that  she  may  formulate 

and  prepare  that  diet  intelligently,  and  this  is  best  done  by  a 

careful  study  of  the  foodstuffs  themselves  as  seen  in  the  following 

table :  ^ 

TABLE   XI 

Chemical  Composition  of  Common  Foods 


Food  Materials  • 


Animal  Food 
Bacon,  smoked,  E.  P.  .  .  . 
Beef  free  from  visible  fat,  E.P. 
Beef,  round  steak,  lean,  E.  P. 
Beef,  sirloin  steak,  E.P.  .  . 
Beef,  porterhouse  steak,  E.  P. 
Beef,  tenderloin,  E.  P.  .  .  . 
Beef,  roast,  cooked  .  .  .  . 
Tenderloin  steak  broiled,  E.  P. 

Sweetbreads,  A.  P 

Brains,  E.  P 

Veal,  breast 


Water 


Per  cent 


20.2 
73.8 
70.0 
61.9 
52.4 
59.2 
48.2 
54.8 
70.9 
80.6 
62.2 


Protein ' 
NX6.25 
Per  cent 


9.9 
22.1 
21.0 
18.9 
19.1 
16.2 
22.3 
23.5 
16.8 

8.8 
20.3 


Fats 


Per  cent 


64.8 

2.9 

7.9 

18.5 

17.9 

24.2 

28.6 

20.4 

12.1 

9.3 

11.0 


Carbohy- 
drates 
Per   cent 


Ash 


Per  cent 


5.1 
1.2 
1.1 
1.0 
0.9 
0.8 
1.3 
1.2 
1.6 
1.1 
1.0 


6  Table  shows  the  distribution  of  the  various  foodstuffs  as  they  occur  in  the 
common  food  materials,  compiled  from  Bui.  28,  U.  S.  Department  of  Agriculture, 
by  Atwater  and  Bryant. 

« Table  compiled  from  Bulletin  28,  Office  of  Experiment  Stations,  U.  S.  Dept. 
Agriculture.  Fuel  values  calculated  from  above  percentage  using  factors :  Protein 
4  calories ;    Fat  9  calories ;  Carbohydrates  4  calories. 

7  Using  the  nitrogen  factor  6.25,  that  is,  for  every  gram  of  nitrogen  there  are  6.25 
grams  of  protein ;    for  example,  to  10  grams  of  nitrogen  there  will  be  6.25  X  10 

=  62.5  grams  protein. 


54 


DIETETICS  FOR  NURSES 


TABLE  XI  — Continued 


Food  Materials 


Animal  Food 

Veal  cutlets 

Veal  kidneys 

Lamb  chops  broiled       .     . 

Roast 

Mutton  leg,  E.  P.      .     .     . 
Roast,  cooked       .... 

Pork,  ham 

Ham,  boiled,  E.  P.    .     .     . 
Chicken,  broilers,  E.  P. 
Chicken,  fowl,  E.  P.      .     . 

Turkey,  E.  P 

Turkey,  roasted,  E.  P.  .     . 

Fish 
Bass,  black,  E.  P.     .     .     . 
Bluefish,  dressed,  E.  P. 
Butterfish,  dressed,  E.  P.    . 
Cod,  dressed,  E.  P.  .     .     . 
Haddock,  dressed,  E.  P.     . 
Halibut,  dressed,  E.  P. 
Herring,  dressed,  E,  P. 
Mackerel,  dressed,  E.  P.     . 
Salmon,  dressed,  E.  P.  .     . 
Shad,  dressed,  E.  P.       .     . 

Shad  roe  

Shellfish 

Clams,  E.  P 

Crabs,  hard  shell,  E.  P. 

Lobster,  E.  P 

Oysters  in  shell,  E.  P.    .     . 
Oysters,  solids,  E.  P.     .     . 

Scallops,  E.  P 

Shrimps,  canned,  E.  P. 

Eggs,  uncooked,  E.  P.  .  . 
Eggs,  boiled,  E.  P.  .  .  . 
Egg  whites,  cooked  .  .  . 
Egg  yolks,  cooked  .  .  . 
Milk  and  Milk  Products 

Whole  milk 

Skimmed  milk      .... 

Whey 

Buttermilk 


Water 

Protein 

Fats 

Carbohy- 

NX6.25 

drates 

Per  cent 

Per  cent 

Per  cent 

Per  cent 

70.7 

20.3 

7.7 

75.8 

16.9 

6.4 

47.6 

21.7 

29.9 

67.1 

19.7 

12.7 

19.8 

12.4 

50.9 

25.0 

22.6 

40.3 

16.3 

38.8 

51.3 

20.2 

22.4 

74.8 

21.5 

2.5 

63.7 

19.3 

16.3 

55.5 

21.1 

22.9 

52.0 

27.8 

18.4 

74.4 

19.4 

4.9 

78.5 

19.4 

1.2 

70.0 

18.0 

11.0 

81.8 

15.6 

.1 

81.7 

17.2 

.3 

75.4 

18.6 

5.2 

72.5 

19.5 

7.1 

74.9 

19.5 

4.6 

63.6 

17.8 

17.8 

70.6 

18.8 

9.5 

71.2 

20.9 

3.8 

2.6 

86.2 

6.5 

.4 

4.2 

77.1 

16.6 

2.0 

1.2 

79.2 

16.4 

1.8 

.4 

86.9 

6.2 

1.2 

3.7 

88.3 

6.0 

1.3 

3.3 

80.3 

14.8 

.1 

3.4 

70.8 

25.4 

1.0 

0.2 

73.7 

13.4 

10.5 

73.2 

13.2 

12.0 

86.2 

12.3 

0.2 

49.5 

15.7 

33.3 

87.0 

3.3 

4.0 

5.0 

90.5 

3.4 

0.3 

0.5 

93.0 

1.0 

0.3 

5.0 

91.0 

3.0 

0.5 

4.8 

Ash 
Per  cent 


THE  FUEL  VALUE  OF  FOOD 


55 


TABLE  XI  — Continued 


Water 

Protein 

Fats 

Carbohy- 

Ash 

Food  Materials 

NX6.25 

drates 

Per  cent 

Per  cent 

Per  cent 

Per  cent 

Per  cent 

Milk  and  Milk  Products 

Koumiss 

89.3 

2.8 

2.1 

5.4 

A 

Condensed  milk  unsweetened, 

A.P 

68.2 

9.6 

9.3 

11.2 

1.7 

Condensed    milk    sweetened, 

A.P 

26.9 

8.8 

8.3 

54.1 

1.9 

Butter 

11.0 

1.0 

85.0 

3.0 

Cheese,  cottage 

72.0 

20.9 

1.0 

4.3 

1.8 

Cheese,  American,  pale      .     . 

31.6 

28.8 

35.9 

.3 

3.4 

Cream  cheese,  full  cream 

34.8 

25.9 

33.7 

2.4 

3.8 

Vegetable  Foods  —  Flour  and 

Meals 

Barley 

11.9 

10.5 

2.2 

72.8 

2.6 

Barley,  pearled     .     .  - 

. 

11.5 

8.5 

1.1 

77.8 

1.1 

Buckwheat  flour  .     . 

. 

13.6 

6.4 

1.2 

77.9 

.9 

Corn  meal,  unbolted 

. 

11.6 

8.4 

4.7 

74.0 

1.3 

Corn  meal,  granular 

. 

12.5 

9.2  n; 

1.9 

75.4 

1.0 

Corn  preparations : 

A 

Cereals     .... 

. 

10.3 

9.6 

1.1 

78.3 

.7 

Hominy,  uncooked   . 

. 

11.8 

8.3 

.6 

79.0 

.3 

Hominy,  cooked  .     . 

. 

79.3 

2.2 

.2 

17.8 

Oatmeal,  boiled 

. 

84.5 

2.8 

.5 

11.5 

.7 

Oatmeal  gruel 

. 

91.6 

1.2 

.4 

6.3 

.5 

Oatmeal  water 

. 

96.0 

.7 

.1 

2.9 

.3 

Rolled  oats 

. 

7.7 

16.7 

7.3 

66.2 

2.1 

Rice,  raw    .     . 

. 

12.3 

8.0 

.3 

79.0 

.4 

Rice,  boiled 

. 

72.5 

2.8 

.1 

24.4 

.2 

Rye  flour     .     . 

. 

12.9 

6.8 

.9 

78.7 

.7 

Wheat  flour,  entire 

11.4 

13.8 

1.9 

71.9 

1.0 

Wheat  flour,  Graham 

11.3 

13.3 

2.2 

71.4 

1.8 

Wheat  flour  roller  process. 

baker's  grade 

11.9 

13.3 

1.5 

72.7 

.6 

Wheat  flour,  family  grade      . 

11.9 

10.9 

1.1 

75.6 

.5 

Wheat  Preparations  and 

Breads 

Cracked  wheat 

10.1 

11.1 

1.7 

75.5 

1.6 

Flaked  wheat        

8.7 

13.4 

1.4 

74.3 

2.2 

Farina          

10.9 

11.0 

1.4 

76.3 

.4 

Macaroni     « 

10.3 

13.4 

.9 

74.1 

1.3 

Macaroni,  cooked     .... 

78.4 

3.0 

1.5 

15.8 

1.3 

Spaghetti 

10.6 

12.1 

.4 

76.3 

.6 

Gluten 

8.9 

13.6 

1.7 

74.6 

1.2 

Brown  bread 

43.6 

5.4 

1.8 

47.1 

2.1 

66 


DIETETICS  FOR  NURSES 


TABLE  XI  — Continued 


Food  Materials 


Wheat    Preparations    and 
Breads 

Rye  bread  » 

Rye  and  wheat  bread  .  . 
Wheat  bread,  white  .     .     . 

Whole  wheat 

Graham  bread      ,     .     .     . 

Gluten  bread 

Biscuit,  homemade  .  . 
Maryland  biscuits     .     .     . 

Rolls 

Crackers,  saltines  .  .  . 
Graham  crackers .... 
Oatmeal  crackers      .     . 

Cake,  cookies 

Cup  cake 

Vegetables 
Asparagus,  cooked,  E.  P. 
Beans,  butter,  E.  P.       .     . 

Beans,  dried 

Beans,  string 

Beets,  cooked,  E.  P.       .     . 

Cabbage,  E.  P 

Carrots,' E.P 

Celery,  E.  P 

Corn,  green,  E,  P.  .  .  . 
Cucumbers,  E.  P.      .     .     . 

Eggplant,  E.  P 

Greens,  turnip      .... 

Lentils,  dried 

Lettuce 

Mushrooms 

Okra 

Onions,  fresh 

Onions,  cooked     .... 

Parsnips 

Peas,  green 

Peas,  dried 

Peas,  cooked 

Potatoes,  raw 

Potatoes,  cooked  .... 
Potatoes,  sweet  .... 
Rhubarb 


Water 
Per  cent 


50.7 

35.3 

35.3 

38.4 

35.7 

38.2 

32.9 

24.6 

29.2 

5.5 

5.4 

6.3 

8.1 

15.6 

91.6 
58.9 
12.6 
89.2 
88.6 
91.5 
88.2 
94.5 
75.4 
95.4 
92.9 
86.7 

8.4 
94.7 
88.1 
90.2 
87.6 
91.2 
83.0 
74.6 

9.5 
73.8 
78.3 
75.5 
69.0 
94.4 


Protein 
NX6.25 
Per  cent 


11.9 

11.9 

9.2 

9.7 

8.9 

9.3 

8.7 

8.4 

8.9 

10.6 

10.0 

11.8 

7.0 

5.9 

2.1 
9.4 

22.5 
2.3 
2.3 
1.6 
1.1 
1.1 
3.1 
.8 
1.2 
4.2 

25.7 
1.2 
3.5 
1.6 
1.6 
1.2 
1.6 
7.0 

24.6 
6.7 
2.2 
2.5 
1.8 
.6 


Fats 
Per  cent 


.6 

.3 

1.^ 

.9 
1.8 
1.4 
2.6 
5.6 
4.1 

12.7 
9.4 

11.1 
9.7 
9.0 

3.3 
.6 

1.8 
.3 
.1 
.3 
.4 
.1 

1.1 
.2 
.3 
.6 

1.0 
.3 
.4 
.2 
.3 

1.8 
.5 
.5 

1.0 

3.4 

0.1 
.1 
.7 
.7 


Carbohy- 
drates 
Per  cent 


51.5 
53.1 

49.7 
52.1 
49.8 
55.3 
60.1 
56.7 
68.5 
73.8 
69.0 
73.7 
68.5 

2.2 

29.1 

59.6 

7.4 

7.4 

5.6 

9.3 

3.3 

19.7 

3.1' 

5.1 

6.3 

59.2 

2.9 

6.8 

7.4 

9.9 

4.9 

13.5 

16.9 

62.0 

14.6 

18.4 

20.9 

27.4 

3.6 

35.9 


Per  cent 


THE  FUEL  VALUE  OF  FOOD 


57 


TABLE  XI  — Continued 


Food  Materials 


Vegetables 
Spinach,  cooked  .     . 

Squash 

Tomatoes,  fresh  .  . 
Tomatoes,  canned  . 
Turnips,  fresh       .     . 

Fruits 
Apples,  E.  P. 
Apple  sauce,  A.  P.  . 
Apricots  .  .  .  . 
Bananas  .  .  .  . 
Blackberries  .  .  . 
Cranberries  .  .  . 
Currants  .  .  .  . 
Dates  (dried)  .  .  . 
Figs,  fresh  .  .  .  . 
Figs,  dried  .     .     .     . 

Grapes    

Lemons 

Lemon  juice     .     .     . 

Oranges  

Peaches  

Pineapple    .     .     .     . 

Plums 

Prunes    

Raisins 

Strawberries     .     .     . 

Almonds  .  .  .  • . 
Chestnuts    .     .     .     . 

Peanuts 

Olive  oil 

Gelatine 

Calf's-foot  jelly    .     . 

Candy     

Honey 

Molasses  .  .  .  . 
Marmalade  (orange) 
Arrowroot  (starch)  . 
Cornstarch .  .  .  , 
Sugar  (granulated)  . 
Sugar  (maple)  .  . 
Sugar  (brown)  .  , 
Tapioca 


Water 

Protein 
NX6.25 

Fats 

Carbohy- 
drates 

Ash 

Per  cent 

Per  cent 

Per  cent 

Per  cent 

Per  cent 

89.8 

2.1 

.3 

3.2 

2.1 

88.3 

1.4 

.5 

9.0 

0.8 

94.3 

.9 

.4 

3.9 

0.5 

94.0 

1.2 

.2 

4.0 

0.6 

89.6 

1.3 

.2 

8.1 

0.8 

84.6 

.4 

.5 

14.2 

0.3 

61.1 

.2 

.8 

37.2 

0.7 

79.9 

1.0 

12.6 

0.5 

75.3 

1.3 

.6 

22.0 

0.8 

86.3 

1.3 

1.0 

10.9 

0.5 

88.9 

.4 

.6 

9.9 

85.0 

1.5 

12.8 

0.7 

15.4 

2.1 

2.8 

78.4 

1.3 

79.1 

1.5 

18.8 

0.6 

18.8 

4.3 

.3 

74.2 

2.4 

77.4 

1.3 

1.6 

19.2 

0.5 

89.3 

1.0 

.5 

5.9 

9.8 

0.4 

86.9 

0.8 

0.2 

11.6 

0.5 

89.4 

0.7 

0.1 

9.4 

0.4 

89.3 

0.4 

0.3 

9.7 

0.3 

78.4 

1.0 

20.1 

0.5 

22.3 

2.1 

73.3 

2.3 

14.6 

2.6 

3.3 

76.1 

3.4 

90.4 

0.1 

0.6 

7.4 

1.0 

4.8 

21.0 

54.9 

17.3 

2.0 

45.0 

6.2 

5.4 

42.1 

1.3 

7.2 

25.8 

38.6 
100.0 

24.4 

2.6 

13.6 

91.4 

.1 

2.1 

77.6 

4.3 

17.4 
96.0 

.7 

18.2 

.4 

81.2 

.2 

25.1 

2.4 

69.3 

3.2 

.6 

.1 

84.5 

2.3 

97.5 
90.0 
100.0 
82.8 
95.0 

.2 

11.4 

.4 

.1 

88.0 

CHAPTER  IV 

SPECIAL    DIETS,     METRIC     SYSTEM,     PERCENTAGE 
CALCULATION,  AND  THERMOMETRY 

There  are  a  number  of  diets  formulated  to  meet  the  various 
normal  and  abnormal  conditions.  In  hospitals  these  are  classified 
as  follows,  for  the  convenience  of  both  nurse  and  doctor : 

House  Diet.  —  That  which  is  served  to  the  hospital  staff,  the 
nurses,  and  those  patients  not  requiring  special  diets. 

Liquid  or  Fluid  Diet.  —  Consisting  of  milk,  nutrient  and  other 
palatable  beverages,  broths,  and  thin  gruels. 

Light,  Semi-solid  or  Convalescent  Diet.  —  Composed  of  thick 
or  cream  soups,  eggs,  toast,  cereals,  custards,  jellies  and  ice  cream, 
and  later  vegetable  purees,  broiled  birds,  chicken,  lamb  chops, 
and  rare  beefsteak. 

Mixed  Diet.  —  The  diet  used  in  normal  conditions  and  for  those 
not  affected  by  any  special  food. 

Special  Diets. — Those  designed  to  be  used  for  certain  pathologi- 
cal conditions,  such  as  scarlet  fever,  nephritis,  etc.  These  diets 
are  classified  as  follows  : 

Milk  Diet.  —  A  diet  in  which  milk  is  the  sole  article  of  food. 

Carbohydrate-free  Diet.  —  One  in  which  the  sugars  and  starches 
are  eliminated. 

Purin-free  Diet.  —  One  in  which  the  foods  rich  in  purin  bases 
are  eliminated.     This  is  used  in  gout,  arteriosclerosis,  etc. 

Salt-free  Diet.  —  Diet  in  which  sodium  chloride  (salt)  is  as  far 
as  possible  excluded.  It  is  used  in  certain  cases  of  nephritis  when 
edema  is  present. 

Nephritic  Diet.  —  A  diet  used  in  nephritis  and  diseases  com- 
plicated by  nephritis  (scarlet  fever).  In  this  diet  the  protein 
foods,  meat  in  particular,  are  restricted,  milk  being  the  exception. 

Diabetic  Diet.  —  A  diet  in  which  the  carbohydrates  are  restricted 
or  eliminated. 

58 


SPECIAL  DIETS  AND  METRIC  SYSTEM  59 

*'  Allen  Treatment  of  Diabetes  "  consists  chiefly  of  **  starva- 
tion "  for  a  given  period  and  a  re-education  of  the  organs  to  a 
toleration  for  carbohydrates. 

Emaciation  Diets.  —  Those  containing  a  high  percentage  of 
fat-forming  foods,  such  as  milk,  cream,  eggs,  cereals,  potatoes, 
etc.,  olive  oil. 

Obesity  Diets.  —  Those  containing  as  few  of  the  fat-forming 
foods  as  possible,  such  as  cream,  olive  oil,  potatoes,  white  bread, 
etc.,  pastry  and  desserts,  candy  and  soda  water,  and  containing 
lean  meats,  fish  or  shellfish  cooked  and  served  without  butter  or 
other  fats,  fresh  or  stewed  fruit  without  sugar,  green  vegetables  and 
salads  served  without  oil  or  other  fats ;  one  egg  a  day  two  or  three 
times  a  week,  coffee  and  tea  without  sugar  or  cream,  toasted 
gluten  bread  (1  slice)  without  butter,  saccharine  substituted  for 
sugar. 

There  are  a  number  of  other  diets,  but  they  come  more  or  less 
under  the  above  heads. 

METRIC  MEASURE 

The  metric  system  is  a  system  of  weights  and  measures  expressed 
in  the  decimal  scale.  The  principal  units  with  which  we  are 
concerned  are : 


The  liter  —  L.                        Cubic  centimeter  - 

-c.c. 

The  gram  —  gm.                    Centigram 

-c. 

Milligram  —  mgm. 

These  units  have  prefixes  to  show  how  they  are  divided  deci- 
mally, i.e. : 

deci.  —0.1 
centi.  —  0.01 
milli.  —  0.001 

TABLE    XII 

Units  op  Weight 

10  milHgrams    =  1  centimeter  (cgm.) 

10  centimeters.  =  1  decigram  (dgm.) 

10  decigrams     =  1  gram  (gm.) 

10  dekagrams    =  1  hektogram  (hgm.) 

10  hektograms  =  1  kilogram  (kilo.) 
1000  kilograms     =  1  metric  ton 


60  DIETETICS  FOR  NURSES 

A  cubic  centimeter  of  water  weighs  1  gram ;  28.35  grams  =  1 
ounce. 

A  liter  of  water  weighs  1  kilogram;  1  kilogram  of  water  =  2.2 
lb. 

Household  Weights  and  Measukes 

4  saltspoons  =  1  tsp. 

3  tsp.  =  1  tbs. 

4  tbs.  =  i  cup  or  I  gill 
8  tbs.  =  ^  cup  or  1  gill 

16  tbs.  =  1  cup  or  I  pint  =  8  oz.  =  227  gm. 

2  cups  (c.)  =1  pint  =  454  gm. 

2  pints  (pt.)  =  1  quart  (qt.)  =  a  little  less  than  1  liter. 

4  qt.  =1  gal. 

2  tbs.  butter  =  1  ounce  (oz.) 

2  cups  butter  (solid)         =  1  pound  (16  oz.) 
2  cups  granulated  sugar  =  1  pound 

4  qt.  =1  gal. 

2  cups  butter  packed  solid  =  16  oz.  =  1  lb. 

2  cups  granulated  sugar  =  16  oz.  =  1  lb. 

2|  cups  powdered  sugar  =  16  oz.  =  1  lb. 

4  cups  flour  (sifted)  =  16  oz.  =  1  lb. 

1  pt.  milk  or  water  =  16  oz.  =  1  lb. 

1  pt.  chopped  meat  =  16  oz.  =  1  lb. 
10  medium  size  eggs  (with  shells)  =  1  lb. 

8  eggs,  without  shells  =  1  lb. 

2  cups  rice  =  1  lb. 
2  tbs.  butter                                     =     1  oz. 

4  tbs.  butter  =    2  oz.  =  |  cup 

2  tbs.  sugar  =    1  oz. 

4  tbs.  flour  (sifted)  =    1  oz. 

4  tbs.  coffee  (powdered)  =     1  oz. 

2  tbs.  powdered  Ume  =     1  oz. 

2  tbs.  lemon  juice  =    1  oz. 

2  tbs.  orange  juice  =     1  oz. 

1  glass  orange  juice  =    8  oz.  or  ^  pint 

2f  cup  oatmeal  =  1  lb. 

4|  cup  rolled  oats  =  1  lb. 

28.35  grams  =  2  tablespoons  =  1  ounce  of  the  following  substances : 
arrowroot,  barley  flour,  brandy,  butter,  grape  juice,  lemon  juice,  orange 
juice,  molasses,  cream,  dry  peptonoids,  hquid  peptonoids,  milk  (whole, 
skimmed),  buttermilk,  malted  milk,  rice  flour,  oatmeal,  olive  oil,  wine. 

Materials  requiring  3  tablespoons  to  weigh  28.35  gm.  or  1  oz. : 
—  corn  meal,  farina,  gum  gluten  flour,  graham  flour,  white  flour. 
Material  requiring  4  tbs.  to  weigh  1  oz. :  cocoa. 
The  standard  measuring  cup  holds  8  ounces  or  16  tablespoonfuls. 


SPECIAL  DIETS  AND  METRIC  SYSTEM  61 

1  ordinary  glass  (water)  =  8  ounces 
1  coffee  cup  =  8  ounces 

1  tea  cup  =  6  ounces 

1  wine  glass  =  2  ounces 

The  following  list  shows  the  approximate  weights  and  measures 
of  the  foods  comprising  dietaries : 


Asparagus,  8  stalks,  E.  P. 

Apple  (1  medium  size) 

Bread,  1  slice,  home-made,  4  in.  >< 

Bread,  1  slice,  baker's,  4  in.  X  3^ 

Bread,  1  slice,  whole  wheat,  2|  in. 

Bread,  1  shce,  corn,  3  in.  X  3    in. 

Bread,  mufi&n,  1  small,  or  biscuit 

Banana,  1  medium  size 

Chicken,  1  serving 

Chicken  (creamed)  2  tbs. 

Cream,  2  tbs. 

Custard  (soft  |  cup) 

Custard  (baked,  ^  cup) 

Cream  (ice  —  ^  cup) 

Custard  (rice  |  cup) 

Dates  (3  medium  size) 

Eggs  (scrambled,  i  cup) 

Eggs  poached,  1  egg 

Fish,  medium  serving,  2^  in.  X  3  in. 

Honey,  4  tsp. 

Hominy  (cooked)  ^  cup 

Lamb  chop,  E.  P.,  2  X  2  X  §  inch 

Lemon  or  other  jellies,  |  cup 

Steak  (sirloin),  3  X  |  X  f  in. 

Vegetables : 

Beets,  1  medium  size  (4  slices) 
Carrots,  |  cup  diced 
Peas  (canned  or  drained)  I  cup 
Potatoes,  baked,  sweet,  1  medium  size 
Potatoes,  baked,  white,  1  medium  size 
Spinach,  cooked,  1  serving,  |  cup 
Tomatoes,  1  medium  size  —  fresh 

Soups : 

Cream,  |  cup 
Clear  soup,  1  cup 


xi' 


m. 


cSf  m. 
in.  X  f  in. 
X  2|  in.  X  i  in. 
X  Un. 


=  2  ounces 
=  5  ounces 
=  1  ounce 
=  1  ounce 
=  .7  ounce 
=  2  ounces 
=  ^  ounce 
=  5  ounces 
=  3  ounces 
=  1|  ounces 
=  1  ounce 
=  4§  ounces 
=  4  ounces 
=  4  ounces 
=  3|  ounces 
=  1  ounce 
=  2  ounces 
=  1^  ounces 
=  2|  to  3  ounces 
=  1  ounce 
=  4  ounces 
=  1.6  ounces 
=  3.8  ounces 
=  3  ounces 

=  2  ounces 
=  2|  ounces 
=  3  ounces 
=  6  ounces 
=  3  ounces 
=  4  ounces 
=  3  to  4  ounces 

=  4  ounces 
=  7^  ounces 


PERCENTAGE  CALCULATION 

A  percentage  of  a  number  is  the  result  obtained  by  taking  the 
stated  number  of  hundredths  of  it.  The  rate  per  cent  is  a  fraction 
whose  denominator  is  100  and  whose  numerator  is  the  given  number 
of  hundredths ;  thus  6%  of  a  number  is  xB^  of  that  number. 


62  DIETETICS  FOR  NURSES 

The  method  of  figuring  the  per  cent  of  foodstuff  in  a  food  material 
is  simple.  Milk,  for  example,  has  a  percentage  composition  of 
3%  protein,  4%  fat,  and  5%  sugar.  To  find  the  definite  amounts 
of  these  foodstuffs  in  1  ounce  of  milk  it  is  best  to  reduce  the  ounce 
to  grams,  since  the  gram  is  the  unit  of  measurement  generally 

^^^^-       1  ounce  =  28.35  grams 

In  1  oz.  there  will  be  28.35  X  .03  =  0.85  gram  protein 
In  1  oz.  there  will  be  28.35  X  .04  =  1.13  grams  fat 
In  1  oz.  there  will  be  28.35  X  .05  =  1.41  grams  sugar 

All  other  foods  are  calculated  in  the  same  manner. 

When  not  only  the  percentage  of  carbohydrate,  fats,  and  proteins 
in  a  material  is  asked  for  but  the  fuel  value  of  that  food  is  also 
demanded,  the  amount  of  each  chemical  combination  in  the  food 
in  grams  is  multiplied  by  its  fuel  factor,  which  has  already  been 
demonstrated  in  Chapter  III.  For  example,  the  value  of  an  ounce 
of  milk  may  be  calculated  as  follows  :   3%  protein  X  28.35  grams 

X  fuel  factor  4  =  28.35  X  .03  =  .85  gm.  protein  X  4  =  3.40  calories 

28.35  X  .04  =  1.13  gm.  fat  X  fuel  factor  9       =  10.17  calories 

28.35  X  .05  =  1.41  gm.  sugar  X  fuel  factor  4  =  5.64  calories 

Total  fuel  value  19.21  calories 

THERMOMETRY 

There  are  two  scales  used  in  thermometry,  the  Fahrenheit 
and  the  Centigrade.  The  former  is  generally  used.  However, 
since  many  of  the  scientific  calculations  are  made  using  the 
Centigrade  scale  it  is  wise  for  the  nurse  to  understand  how  to 
translate  one  to  the  other. 

Centigrade  has  0°  as  the  freezing  point  and  100°  as  the  boiling 
point,  while  Fahrenheit  has  32°  as  freezing  point  and  212°  as  boil- 
ing point.  To  change  Fahrenheit  to  Centigrade  it  is  necessary  to 
subtract  32  from  212  in  order  to  make  the  freezing  points  corre- 
spond. This  would  read  212  -  32  =  180°  F.  =  100°  C. ;  hence  a 
degree  Centigrade  represents  f  of  a  degree  Fahrenheit. 

To  change  Centigrade  to  Fahrenheit  it  is  necessary  to  remember 
that  every  Fahrenheit  degree  is  f  times  as  large  as  the  Centigrade 
and  the  addition  of  32°  must  also  be  made.  For  example  :  Change 
105°  F.  to  Centigrade :  105°  -  32°  X  f  =  41°  C.  Change  50°  C. 
to  Fahrenheit :  50°  X  |  +  32°  =  90°  +  32°  =  122°  F. 


CHAPTER  V 

FORMULAS  FOR  THE  PREPARATION  OF  FOOD  FOR 

THE  SICK 

Beverages 

Peptonized  Milk 

1  pt.  of  milk  1  tube  of  (Fairchild's)  peptonizing  powder 

Dissolve  the  powder  in  1  gill  of  cold  water,  and  place  in  a  clean 
quart  jar  (glass). 

Pour  in  1  pint  of  cold  milk  and  stop  the  bottle  with  cotton, 
shake  well  and  place  the  bottle  in  a  saucepan  containing  water 
just  warm  enough  ,to  allow  of  the  hand  being  immersed  without 
being  burned  (115°  F.). 

Keep  the  water  at  this  temperature  for  5  to  10  minutes  or  longer 
according  to  the  degree  of  peptonization  desired.  Lift  out  of  the 
warm  water  and  plunge  into  cold,  then  place  at  once  on  ice. 

The  milk  may  be  poured  from  bottle  into  a  clean  saucepan  and 
brought  quickly  to  a  boil  to  prevent  further  peptonization ;  this 
process,  however,  is  apt  to  make  the  milk  very  bitter  and  should 
not  be  used  unless  it  is  to  be  flavored  with  fruit  juice. 

Albumenized  Milk 
6  ounces  (f  glass)  fresh  whole  milk.       1-2  eggs  (whites  only) 

Have  the  milk  thoroughly  chilled. 

Clip  egg  whites  with  scissors  and  strain  through  cheesecloth  to 
remove  stringy  parts.     Now  stir  into  the  milk  with  a  fork. 

If  patient  does  not  object  to  foam,  the  mixture  may  be  placed 
in  a  milk  shaker  with  pieces  of  ice  and  shaken  until  creamy,  then 
poured  over  cracked  ice. 

63 


64  DIETETICS  FOR  NURSES 

BUTTEKMILK   (BULGARIAN) 

1  qt.  fresh  whole  milk  (or  skimmed  if  desired) 

1|  to  2  oz.  (Bulgarian)  starter,  or  1  buttermilk  tablet  ^ 

If  latter  is  used  dissolve  tablet  in  1  gill  of  cold  water. 

Stir  the  buttermilk  starter  into  the  cold  milk  and  place  in  a  one- 
half  gallon  glass  jar,  place  the  cover  on  loosely  and  allow  the  jar 
to  stand  for  12  hours  or  until  the  milk  is  well  clabbered.  (Insert 
a  thin-bladed  knife  close  to  the  jar  so  that  the  rest  of  the  milk  is 
not  disturbed  to  see  if  the  coagulation  is  complete.)  When  this 
is  accomplished  place  the  jar  in  the  ice-box.  After  the  milk  has 
become  thoroughly  cold,  beat  thoroughly.  The  mixture  is  like 
any  well-made  buttermilk.  If  the  cream  is  removed  before  add- 
ing the  culture  the  milk  will  be  of  lower  nutrient  value,  but  in 
many  cases  this  is  necessary  since  it  is  often  the  fats  which  cause 
a  disturbance. 

Lactone  Buttermilk    , 

627  calories 

1  qt.  fresh  milk  1  gill  cold  water 

1  lactone  tablet  (or  Ij  oz.  buttermilk  starter) 

(Parke,  Davis  &  Co.'s  and  Hansen  &  Co.'s  buttermilk  tablets  are 
practically  the  same.) 

Dissolve  tablet  in  cold  water  and  stir  into  fresh  milk  (which 
may  or  may  not  be  skimmed,  according  to  the  directions  of  the 
physician,  but  the  finished  product  is  more  palatable  using  whole 
milk).  Pour  into  a  clean  jar  or  wide-mouthed  bottle ;  plug  with 
cotton  or  close  not  tightly,  allow  to  stand  in  room  temperature 
70°-75°  F.  for  24  hours,  shaking  the  bottle  occasionally  to  keep  the 
cream  from  rising.  At  the  end  of  this  time  pour  the  milk  out  (if 
sufficiently  fermented),  and  beat  briskly  for  5  to  6  minutes  with 
egg  beater  or  with  churn,  place  on  ice  until  ready  to  serve. 

^  Buttermilk  Tablets  may  be  purchased  from  the  Chas.  Hansen  &  Co.  Lab.,  N.  Y., 
or  from  Parke,  Davis  &  Co.  The  Buttermilk  Starter  is  prepared  by  the  first  men- 
tioned firm  and  is  ready  to  use,  directions  coming  with  each  sample. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    65 

Albumenized  Milk  Shake 

130.6  calories 

6  oz.  (I  glassful)  fresh  whole  milk  1  egg  white 

Place  the  milk  on  ice  to  become  thoroughly  chilled.  Clip  the 
egg  white  with  scissors  and  strain  through  cheesecloth  to  free  it 
from  strings ;  stir  into  cold  milk.  If  patient  does  not  object  to 
foam,  the  milk  and  egg  whites  may  be  placed  in  a  milk  shaker, 
and  agitated  for  4  or  5  minutes,  then  poured  over  cracked  ice. 
Th  is  beverage  may  be  flavored  to  suit  the  taste  of  patient.  Vanilla, 
caramel,  or  coffee  may  be  used  to  give  variety. 

To  add  additional  nourishment  1  teaspoonful  of  Sanatogen,  or 
Plasmon  may  be  added,  or  1  tablespoonful  of  Panopepton  or 
liquid  peptonoids  used  instead  of  the  casein  products. 

Milk  Punch 

373.5  calories  plus  13  when  egg  is  added 

4  oz.  rich  milk  1  tbs.  whisky  (or  sherry) 

2  oz.  cream  1  tbs.  sugar  (or  less) 

1  egg  white  (if  additional  nourishment  is  desired) 

A  grating  of  nutmeg  on  top.  Place  ingredients  in  shaker  as 
directed  above,  and  shake  a  few  minutes  to  thoroughly  njix  in- 
gredients. Pour  over  cracked  ice,  grate  nutmeg  or  cinnamon  over 
the  top.  The  milk  may  be  peptonized  if  necessary,  using  ^  tube 
of  Fairchild's  peptonizing  powder. 

Peptonized  Milk  Punch 

196.7  calories 

Take  a  goblet  about  one-third  full  of  finely  crushed  ice,  add  a 
tablespoonful  of  St.  Croix  rum,  a  dash  of  Curasao  or  any  liquor  that 
is  agreeable  to  the  taste ;  fill  the  glass  with  "  specially  peptonized 
milk,"  stir  well,  and  grate  a  little  nutmeg  on  top.  Add  1  tablespoon 
sugar. 


66  DIETETICS  FOR  NURSES 

"Specially  peptonized  milk"  ^  may  be  used  in  the  same  way  as 
fresh  milk  in  making  punches  —  with  St.  Croix  rum  or  Jamaica, 
or  any  spirits  that  may  be  preferred. 

Plain  Eggnog 

233.7  calories 

1  egg  1  tbs.  rum 

2  tbs.  cream  1  tbs.  whisky 

1  tbs.  sugar 

Beat  yolk  of  egg  and  sugar  together;  add  cream,  rum,  and 
whisky.  Beat  egg  white  stiff  and  stir  into  the  mixture;  pour 
into  glass  with  or  without  cracked  ice. 

Nutmeg  may  be  grated  over  top  for  those  who  like  it. 

Orangeade 
81  calories 
Juice  of  1  orange  Juice  of  ^  lemon 

1  tbs.  sugar  Enough  water  to  fill  the  glass 

Sweeten  the  juice  of  orange  and  lemon  and  pour  into  a  glass 
filled  with  crushed  ice.     Fill  glass  with  plain  or  carbonated  water. 

Albumenized  Orangeade 
107  calories 
Make  orangeade  as  directed  in  above  recipe,  without  the  addi- 
tion of  water.  Break  the  whites  of  2  eggs  into  a  saucer  and  with 
scissors  cut  the  albumen  until  free  from  membrane  and  strain, 
stir  this  into  the  orange  juice  and  add  several  pieces  of  cracked 
ice.  This  is  both  nourishing  and  palatable,  and  the  taste  of  the 
egg  cannot  be  detected. 

Albumenized  Lemonade 
73  calories 
Juice  of  1  lemon  1  tbs.  sugar 

Whites  of  2  eggs 

2  See  Fairchild's  Formula. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    67 

Cut  as  directed  for  xAlbumenized  Orangeade.  Mix  until  sugar 
is  dissolved.  Pour  over  a  glassful  of  cracked  ice.  Fill  glass  with 
plain  or  carbonated  water. 

Albumenized  Grape  Juice 
146  calories 

Albumenized  Grape  Juice  is  made  without  the  addition  of  lemon 
juice  unless  the  white  grape  juice  is  substituted  for  the  black,  in 
which  case  add  one  or  two  teaspoonfuls  to  relieve  the  flat  taste  and 
proceed  as  in  Albumenized  Orangeade,  using  3  oz.  of  grape  juice. 

Milk  and  Ginger  Ale  (or  Sarsaparilla) 
3  oz.  milk  3  oz.  ginger  ale  or  sarsaparilla 

Pour  into  a  milk  shaker  and  shake  with  cracked  ice  until 
foamy. 

Malted  Milk  (1) 

1  tbs.  malted  milk  6  oz.  boiling  water 

1-2  tsp.  sugar  j  tsp.  salt,  3-5  drops  vanilla 

Heat  water  to  boiling  and  mix  malted  milk  (Horlick's)  with  a 
little  cold  water.  Stir  into  the  boiling  water,  add  sugar  and  salt, 
and  serve  with  or  without  cream. 

Malted  Milk  (2) 

J  to  1  tbs.  malted  milk  1-2  tsp.  sugar 

3  oz.  each  milk  and  water  or  J  tsp.  salt 
Proceed  as  above. 

Malted  Milk  Chocolate  or  Cocoa 

1  tbs.  malted  milk  2  oz.  water 

1  tbs.  cocoa  or  grated  chocolate  1-2  tsp.  sugar 

6  oz.  milk  ,  4-5  drops  vanilla  extract 

Mix  cocoa  or  chocolate  with  water  and  boil  2-3  minutes. 
Pour  milk  into  a  double  boiler  and  heat,  mix  malted  milk  with  a 


68  DIETETICS  FOR  NURSES 

little  water  and  stir  into  the  hot' milk,  add  the  cocoa  paste,  sugar, 
and  vanilla,  mix  thoroughly,  beat  the  mixture  briskly  to  mix 
ingredients  thoroughly,  and  serve  with  or  without  cream. 


Malted  Milk  Eggnog 

1  egg  1  tbs.  sherry  wine  or  whisky 

1  tbs.  malted  milk  J-1  tbs.  sugar 

4  oz.  milk  1  tsp.  cream 

Mix  milk  as  directed  above  and  chill  thoroughly.  Beat  egg 
yolk  with  sugar  and  whisky  or  wine  and  add  to  the  mixture. 
Beat  egg  white  stiff  and  stir  into  the  rest  of  the  ingredients.  Pour 
into  shaker  and  shake  with  cracked  ice  until  thoroughly  chilled. 
The  cream  may  be  served  on  top,  or  beaten  into  the  eggnog. 

Egg  White  and  Mint 
60.5  calories 

1  egg  1  tsp.  lemon  juice 

2  tsp.  sugar  Several  sprigs  of  fresh  spearmint 

Whip  white  of  egg ;  add  sugar  and  lemon  juice.  Crush  lower 
parts  of  mint  leaves  slightly  and  place  in  glass.  Pour  mixture 
over  ice  in  glass ;  stir  well  and  serve  at  once. 

Fill  glass  with  carbonated  water,  Vichy,  White  Rock,  Apollina- 
ris,  etc.  This  is  especially  good  when  patient  suffers  from 
nausea. 

Champagne  Mint  Julep 

Two  drops  of  Angostura  Bitters  on  one  lump  of  cut  sugar. 

Dissolve  sugar  in  one  tablespoonful  of  water.  Place  in  glass  of 
cracked  ice  with  several  sprigs  of  fresh  spearmint,  and  fill  the 
glass  with  any  sweet  champagne.     Stir  the  mixture  before  serving. 

As  a  beverage,  California  champagne  will  answer  admirably  in 
this  recipe,  as  sweet  champagne  is  preferable  to  the  dry. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    69 

Panopepton  and  Liquid  Peptonoids  Eggnog 
280  calories 

Is  made  as  directed  for  plain  eggnog,  panopepton  being  sub- 
stituted for  the  rum,  using  1  ounce  instead  of  1  tablespoonful. 
This  will  probably  more  than  fill  a  glass,  but  the  whole  amount 
must  be  made  to  keep  the  proportions  correct.  The  whisky 
may  be  left  in,  if  desired,  or  sherry  wine  may  be  substituted  in 
its  place  to  give  flavor  and  additional  stimulation. 

Coffee  Eggnog 

Follow  recipe  for  plain  eggnog,  substituting  2  tablespoonfuls 
of  strong  coffee  for  the  rum. 

PiNEAPPLEADE 

100.9  calories 

2  oz.  (J  cup)  grated  pineapple  Juice  of  1  lemon 

8  oz.    (1    cup)    cold  water,    or  1  drop  of  lemon  extract  or  a 

sufficient  quantity  carbonated        little  of  the  peel,  grated 

water  to  fill  glass  1  tbs.  sugar 

Mix  lemon  ^ juice,  water,  and  pineapple  together ;  add  sugar,  if 
not  sweet  enough,  but  the  less  used  the  better,  in  all  beverages. 
Add  extract  and  pour  into  a  shaker  with  a  few  lumps  of  ice. 
Shake  well  to  mix  ingredients  and  pour  the  pineapple  over  crushed 
ice.  If  this  proves  too  much  at  a  time,  make  half  the  recipe. 
Serve  in  tall  thin  glasses  holding  from  4  to  6  ounces  after  the  ice 
is  put  in,  or  serve  in  punch  glasses  with  small  spoons. 

Cream  Egg  and  Vichy 
376.7  calories 

1  egg  white  3  oz.  (6  tbs.)  cream 

2  tsp.  sugar  A  few  drops  of  vanilla  extract 

Celestine  (French)  Vichy  to  fill  glass 


70  DIETETICS  FOR  NURSES 

Whip  egg  white  to  stiff  froth;  whip  cream  stiff  and  sweetfen, 
add  vanilla;  lastly,  the  egg.  Pour  over  cracked  ice  and  fill  up 
the  glass  with  Vichy. 

Cocoa 

231.6  calories 

2  tsp.  cocoa  i  cup  boiling  water 

1-2  tsp.  sugar  f  cup  milk 

Mix  cocoa  and  sugar  together  and  add  boiling  water  slowly. 
Boil  3  to  5  minutes;  heat  milk  in  double  boiler  and  add  cocoa 
mixture.  Beat  with  Dover  egg  beater  to  distribute  cocoa  and 
prevent  scum  forming.  Serve  with  or  without  whipped  cream. 
Cocoa  may  be  reinforced  as  directed  in  "broths*'  with  albumen 
or  the  whole  or  yolk  of  one  egg  well  beaten.  If  the  white  alone  is 
used,  care  must  be  observed  that  the  liquid  is  not  hot  enough  to 
coagulate  the  albumen.  Proprietary  foods  and  casein  prepara- 
tions are  used  in  like  manner. 

Coffee 

2  tbs.  ground  coffee  1  cup  boiling  water 

2  tsp.  white  of  egg  J  cup  cold  (boiled)  water 

Mix  coffee  with  1  tablespoonful  of  cold  water  and  egg  white  in 
small  pot  (after  scalding  pot),  add  boiling  water;  allow  to  boil  3 
minutes ;  stir  down  and  add  cold  water ;  set  pot  where  coffee  will 
stay  hot,  but  not  boil,  for  10  to  15  minutes,  serve  with  cream  and 
sugar  or  use  to  flavor  hot  milk. 

Broths 

Method  of  Making  Standard  Broths 

{Beef,  mutton,  veal,  and  chicken) 

IJfi  calories 

With  rice,  2Ifi  calories;  with  barley,  320  calories 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    71 

Two  pounds  of  meat  (beef,  mutton,  veal,  or  chicken) ;  2  quarts 
of  water ;  2  pounds  of  bones ;  1  teaspoonful  of  salt ;  2  tablespoon- 
fuls  of  rice  or  barley  may  be  added  if  desired  and  parsley  or 
celery  may  be  used  to  give  the  additional  flavor. 

Wipe  meat  with  a  clean  wet  cloth  and  cut  into  small  pieces, 
break  the  bones,  place  all  together  in  a  deep  saucepan,  cover  closely 
and  allow  to  stand  in  a  cool  place  for  one  hour ;  then  place  pan 
on  the  back  part  of  the  stove,  or  on  an  asbestos  mat  over  a  gas 
burner,  and  heat  gently  to  the  boiling  point  (broth  must  never  do 
more  than  simmer) ,  allow  to  simmer  for  three  or  four  hours,  skim, 
strain,  and  cool.  When  thoroughly  cold,  remove  all  of  the  fat, 
using  blotting  paper  to  absorb  the  fine  particles  of  grease.  If 
parsley  and  celery  are  to  be  used  to  flavor  the  broth  they  may  be 
added  during  the  last  hour  of  cooking.  Barley  requires  to  be 
soaked  overnight  when  it  is  used  in  broth ;  rice  should  be  soaked 
one  hour.  When  either  are  to  be  left  in  the  broth  it  is  better  to 
cook  the  broth  for  three  hours,  strain,  return  to  the  fire,  adding 
the  rice  or  barley.  Allow  it  to  simmer  for  an  hour  or  more  and 
proceed  as  directed.  When  the  broth  is  taken  from  the  fire,  it 
should  be  measured,  and  boiling  water  added  to  bring  the  amount 
up  to  the  original  quantity.  This  will  give  what  is  known  as 
standard  broth.  Bouillon  is  clarified  broth,  most  of  the  already 
small  amount  of  nutrient  material  being  thus  strained  and  cleared 
from  the  broth,  leaving  a  liquid  of  practically  no  fuel  value. 

Clam  or  Oyster  Broth 

11.5  calories  without  milk;  162.5  calories  with  milk 

1  doz.  clams  or  oysters  1  pt.  water  or 

1  tbs.  whipped  cream  1  cup  each  milk  and  water 

A  dash  of  pepper 

Scrub  clams  and  place  in  an  iron  spider  and  allow  to  heat  gently 
until  the  shells  open.  (When  oysters  are  used  allow  to  heat  until 
the  edges  curl.)  Chop,  cover  with  hot  water,  and  allow  to  simmer 
15  minutes,  strain  through  cloth,  add  salt  and  a  dash  of  pepper. 


72  DIETETICS  FOR  NURSES 

If  milk  is  to  be  used  in  place  of  part  of  the  water,  add  it  during  the 
last  5  minutes  of  the  cooking.  Clam'  broth  without  milk  may  be 
served  hot  or  cold ;  it  will  not  jelly  as  other  broths  but  may  be 
frozen  if  desired. 

Clam  Broth 

Without  milk,  55.6  calories;  with  milk,  113.4  calories 

J  cup  (4  oz.)  clam  juice  Salt  and  pepper  to  taste 

J  cup  hot  water  or  milk  1  tbs.  whipped  cream 

Mix  clam  juice  (bottled)  with  water ;  heat,  add  salt  and  pepper, 
pour  into  cup,  place  whipped  cream  on  top,  and  serve  at  once. 

Beef  Juice 

One-fourth  pound  lean  beef.  Wipe  clean  with  damp  cloth,  cut 
in  inch  pieces  and  sear  on  a  hot  griddle,  place  in  a  meat  press  and 
remove  all  juice  from  meat.  Care  must  be  taken  not  to  cook  the 
meat.  The  juice  may  be  reheated  by  placing  in  a  hot  cup  in  hot 
water,  not  allowing  the  temperature  to  exceed  155°  F. 

Chicken  Jelly 

308  calories 
1  serving,  75.8  calories 

^  small  chicken  1  tbs.  gelatine  soaked  in 

3  pt.  water  i  cup  cold  water 

I  cup  celery  |  tsp.  salt 

1  sprig  of  parsley  \  tsp.  red  pepper 

1  egg  white 

Cut  the  chicken  in  pieces,  break  the  bones,  place  in  a  saucepan 
with  all  of  the  ingredients  except  the  gelatine  and  G^gg  white,  cover 
with  the  water  and  boil  until  the  meat  falls  from  the  bones.  Press 
out  as  much  of  the  juice  as  possible,  strain  and  allow  to  cool,  re- 
move all  of  the  grease,  and  return  to  the  fire.  Reduce  to  1  pint, 
add  the  gelatine,  stir  in  the  beaten  egg  white,  and  allow  to  boil 
5  minutes,  strain  again  into  molds  and  set  aside  to  congeal. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    73 

Calf's-foot  Jelly 
376.6  calories 
2  small  calf's-feet  1  lemon 

I  small  fowl  J  stick  of  cinnamon 

1  cup  of  Rhine  wine  1  egg  white  (well  beaten) 

Cut  the  fowl  and  the  calf's-feet  into  small  pieces  and  place 
them  in  a  saucepan  with  3  pints  of  cold  water  and  the  cinnamon. 
Cook  until  the  meat  falls  from  the  bones  (the  quantity  should  be 
reduced  to  1  pint).  Strain  and  squeeze  out  as  much  of  the  juice 
as  possible,  allow  to  cool,  and  remove  all  of  the  grease.  Add  wine 
and  lemon  juice  (and  sugar  if  desired)  and  reduce  the  amount  of 
broth  one-half,  add  the  egg  white  and  allow  to  boil  5  minutes. 
Clear  and  strain  into  molds. 

Tomato  Jelly 
103  calories  (plain) 
1  cup  tomatoes  (canned)         J  cup  vinegar 
f  cup  water  1  tbs.  of  parsley 

6  cloves  i  tsp.  red  pepper 

i  cup  celery  1  tbs.  granulated  gelatine 

soaked  in  J  cup  cold  water 

One  slice  of  onion  may  be  added  if  there  is  nothing  to  contra- 
indicate  it,  but  care  must  be  taken  in  adding  onion,  as  it  is  apt  to 
disagree  with  many  people.  Boil  all  of  the  ingredients  together 
(except  the  gelatine)  for  20  minutes,  press  through  a  sieve,  then 
through  a  cloth,  return  to  the  stove  and  allow  to  boil  up ;  add  the 
gelatine  and  boil  5  minutes ;  strain  into  wet  molds. 

One-half  cup  each  of  chopped  chicken  and  celery  or  J  cup  of 
chopped  nuts  may  be  added  to  the  jelly  before  it  congeals  if  de- 
sired, but  care  must  be  taken  not  to  add  anything  without  finding 
out  whether  or  not  it  is  contraindicated. 

Cream  Sauce  for  Cream  Soups 
2  tbs.  flour  1  pt.  milk  or  thin  cream 

2  tbs.  butter  J  tsp.  salt 


74  DIETETICS  FOR  NURSES 

Cream  butter  and  flour  to  a  smooth  paste,  heat  milk  in  double 
boiler  on  an  asbestos  mat  over  the  flame ;  when  it  is  scalding  hot, 
stir  in  the  butter  and  flour  paste,  stir  until  smooth  and  the  mixture 
begins  to  thicken,  cover  and  allow  to  cook  without  boiling  for  15 
minutes ;  strain.  The  sauce  may  be  used  at  once  or  put  into  a 
glass  jar  in  the  ice-box  until  needed. 

Cream  of  Asparagus  Soup 
199  calories 
f  cup  cream  sauce  J  cup  asparagus  puree 

Heat  sauce  and  puree  in  sep,arate  saucepans,  and  when  about 
ready  to  serve,  stir  them  together,  strain  carefully,  season  with 
salt,  and  serve  with  or  without  croutons  of  toast  or  whipped  cream. 
If  the  sauce  is  made  from  the  cream  instead  of  milk,  the  fuel  value 
will  be  much  higher  (302.7  calories). 

Cream  of  Asparagus 

296  calories 

8  medium  stalks  of  asparagus  1  tsp.  salt 

1  qt.  water  1  tbs.  flour 

I  cup  cream  sauce 

Cut  off  the  tips  of  the  asparagus  in  1-inch  pieces,  and  place 
with  the  rest  in  a  saucepan,  and  cover  with  water ;  add  salt  and 
cook  until  the  tips  are  tender ;  lift  out  and  put  aside  to  be  used 
instead  of  the  toast  croutons.  After  the  water  in  which  the  aspara- 
gus is  cooked  is  of  sufficiently  strong  flavor,  strain  and  add  the 
extra  spoonful  of  flour,  mixed  in  a  tablespoonful  of  water;  cook 
15  minutes,  measure  |  cupful,  and  proceed  as  directed  above. 

Cream  of  Potato 
269  calories 

1  medium  size  potato  J  tsp.  salt 

j  cup  milk  I  tbs.  each  flour  and  butter 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    75 

Boil  and  cream  the  potato.  Make  sauce  and  add  potato  puree ; 
stir,  until  well  blended  and  serve  with  toast  croutons. 

When  boiling  potata  if  a  sprig  of  parsley  is  added  and  strained 
out,  and  a  little  of  the  potato  water  is  used  to  make  the  puree 
smooth,  the  soup  will  have  more  character. 

Oyster  Soup 

199.6  calories 
6  oysters  |  cup  milk 

1  cracker  (soda)  or  \  tsp.  salt 

8  oyster  crackers  A  dash  of  pepper 

Put  oysters  (and  their  liquor)  into  a  saucepan,  and  heat  gently ; 
skim  thoroughly.  Heat  milk  in  separate  pan ;  when  very  hot 
add  to  oysters.  Roll  the  cracker  and  add  to  soup  just  before  it 
is  served.    Add  salt  and  pepper  at  the  same  time. 

Cream,  Spinach,  Celery,  Pea,  or  Carrot  Soup 

300  calories  (approximately) 
J  cup  cream  sauce  i  cup  vegetable  pur6e 

Proceed  as  in  making  cream  of  asparagus  soup. 

Eggs 
Method  of  Preparation 

Eggs,  like  other  protein  foods,  must  be  cooked  at  a  low  tem- 
perature to  be  digestible.  A  properly  cooked  egg  should  be  tender 
and  delicious.  Boiling  toughens  the  albumen  and  prevents  its 
ready  digestion,  while  cooking  just  under  the  boil  gives  an  egg 
whose  white  is  of  the  consistency  of  jelly.  To  cook  to  a  firmer 
consistency  it  must  be  left  in  the  hot  water,  but  not  boiled,  for  a 
longer  period ;  see  below. 

Coddled  Eggs 

61  calories 
1  pt.  water  1  egg 


76  DIETETICS  FOR  NURSES 

Allow  water  to  boil;  wash  egg;  drop  into  boiling  water  and 
place  saucepan  where  water  will  keep  hot,  but  not  boil;  allow. to 
stand  7  to  8  minutes.     Serve  with  salt. 

Soft-cooked  Eggs 

61  calories 

Proceed  as  for  coddled  eggs,  but  allow  egg  to  remain  from  10  to 
15  minutes  or  even  longer,  if  very  soft  eggs  are  not  desired. 

Poached  Eggs 

61  calories 

Have  small,  shallow  saucepan  half  filled  with  boiling  water  or 
milk  —  if  an  e^gg  poacher  is  at  hand,  use  that ;  otherwise,  lower  a 
flat  perforated  spoon  into  water  and  place  where  the  water  can- 
not boil.  Break  the  egg  carefully  into  the  spoon,  taking  care  not 
to  break  the  yolk ;  allow  to  stand  in  hot  water  until  the  white  is 
of  the  consistency  of  jelly ;  lift  out  —  slide  egg  on  to  hot  toast, 
taking  care  not  to  break.  (A  broken  poached  egg  is  very  un- 
appetizing, as  well  as  untidy  in  appearance.) 

Creamed  Egg  on  Toast 

With  cream,  175.5  calories;  with  milky  117.0  calories 

Cut  the  crust  from  one  slice  of  bread  and  cut  bread  in  one-inch 
cubes ;  toast  while  preparing  egg.  Beat  egg  with  egg  beater  until 
light  colored;  stir  into  it  2  tablespoonfuls  of  rich  milk;  pour 
into  a  double  boiler,  over  hot  water ;  add  1  teaspoonful  butter,  a 
little  salt  and  pepper ;  stir  until  like  thick  boiled  custard.  Pour 
over  toasted  cubes  of  bread  and  serve  at  once. 

Egg  Nests 

188  calories 

1  egg  .  1  slice  of  bread  (f  in.  thick) 

J  tbs.  butter  Salt  and  pepper  to  taste 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    77 

Toast  the  bread  on  one  side,  butter  and  place  on  a  plate  (one 
which  will  not  break  in  the  oven). 

Beat  egg  white  stiff,  and  pile  roughly  upon  the  toast,  leaving  a 
slight  depression  in  the  center.  Slip  the  unbroken  yolk  into  the 
depression  (take  care  not  to  break  the  egg  yolk  or  the  appearance 
and  significance  of  the  dish  will  be  ruined).  Set  plate  in  oven  to 
brown  the  white  (the  oven  must  not  be  too  hot  or  the  white  will 
brown  before  the  yolk  is  sufficiently  cooked  to  be  palatable). 
Place  the  remaining  butter  on  the  yolk,  dust  with  salt  and  pepper 
and  serve  at  once. 

Foamy  Omelet 

1  egg  i  tbs.  butter 

1  tbs.  water  i  tsp.  salt  and  dash  of  pepper 

Beat  yolk  until  light  colored  and  thick;  add  water,  salt, 
and  pepper.  Beat  white  until  stiff  and  dry.  Turn  the  yolk 
over  the  beaten  white  and  cut  and  fold  the  white  into  the  yolk 
mixture. 

Have  pan  hot  and  buttered,  turn  in  the  mixture,  spread 
evenly  in  pan  and  allow  to  stand  about  two  minutes  on  the 
top  of  the  stove  at  a  moderate  heat;  then  remove  the  pan, 
place  in  a  moderate  oven  and  cook  until  a  knife  thrust  into  the 
center  comes  out  nearly  clean.  Rernove  from  oven,  cut  across 
center  at  right  angles  with  handle  of  pan  and  turn  over  on  a 
hot  platter.  Omelets  may  be  varied  by  the  use  of  different 
garnishes  and  flavors. 

Cream  Toast 
102.6  calories 
1  slice  bread  1  tsp.  flour 

J  cup  thin  cream  1  tsp.  butter 

J  tsp.  salt 

Cream  butter  and  flour  together  cold,  and  stir  into  hot  milk. 
Stir  until  the  mixture  begins  to  thicken,  cover  the  boiler  and  allow 


78  DIETETICS  FOR  NURSES 

to  cook  for  15  minutes.  Slice  the  bread  and  cut  into  cubes ;  toast 
a  delicate  brown,  and  pour  over  it  the  cream  sauce.  Strain  the 
sauce  if  there  are  any  lumps. 

Milk  Toast 

102.6  calories 

1  slice  bread,  toasted  J  cup  milk,  heated 

1  tsp.  butter  i  tsp.  salt 

Toast  the  bread  on  both  sides  and  butter ;  place  in  a  deep  plate 
and  pour  over  it  the  hot  milk. 

Wine  Panada 

184-4  calories 
2  water  crackers  |  cup  hot  or  cold  milk 

2  tbs.  sherry  wine  |  tsp.  grated  nutmeg 

Sugar  may  be  sprinkled  over  crackers  if  desired,  but  it  is  not 
ordinarily  done. 

Place  the  crackers  in  a  deep  plate  and  pour  over  each  cracker 
1  tablespoonful  of  wine,  dust  with  nutmeg  and  pour  over  the  hot 
or  cold  milk. 

Bran  Gems  No.  1 

547.7  calories 

2  tbs.  molasses  1|  cup  bran 

i  tsp.  salt  I  tsp.  soda 

I  cup  milk  1  egg 

Mix  soda  into  bran,  add  salt,  stir  milk  and  molasses  together 
and  stir  into  bran ;  add  well-beaten  egg.  Bake  in  6  well-greased 
gem  pans. 

Bran  Gems  No.  2 

653.6  calories 
1^  cups  bran  1  egg 

1  tbs.  sugar  1  cup  milk 

2  tbs.  melted  butter  2  tsp.  baking  powder 

Mix  together  and  bake  in  6  well-greased  gem  pans. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    79 


1  cup  bran 

f  cup  wheat  flour 


Bran  Biscuits 
463.1  calories 
I  tsp.  salt 


2  tbs.  butter  and  lard  mixed 


If  tsp.  baking  powder 

About  f  cup  of  milk.  (If  this  is  not  sufficient  to  make  a  soft 
dough,  add  more.) 

Mix  flour,  bran,  salt,  and  baking  powder  together.  Mix  in  the 
butter  and  lard.  Add  milk  to  make  dough  mold  into  biscuits 
and  bake  in  a  quick  oven  10  to  12  minutes. 


Bran  Cookies 
188,3  calories 


^  cup  sugar 
I  cup  molasses 
I  cup  milk 
J  cup  butter 
J  cup  flour 
1  cup  bran 


1  tsp.  cinnamon 

1  tsp.  ginger 
J  tsp.  cloves 
J  tsp.  nutmeg 

2  eggs 

f  tsp.  salt 


Cream  butter  and  sugar  together.  Sift  the  spices  and  salt  into 
the  bran  and  flour.  Add  eggs  and  milk  to  butter  and  sugar. 
Stir  in  the  bran  mixture.  Drop  from  spoon  on  to  a  greased  paper. 
Bake  in  a  quick  oven. 

Almond  Biscuits 

209,4  calories 

To  each  ounce  (2  tablespoonfuls)  of  almond  flour,  add  whites 
of  two  eggs  and  salt  to  taste. 

Add  salt  to  eggs ;  beat  until  stiff ;  add  almond  flour  and  bake 
in  small  buttered  pans  for  15  to  20  minutes.  The  whole  process 
must  be  done  quickly,  and  baked  as  soon  as  the  ingredients  are 
mixed. 


80  DIETETICS  FOR  NURSES 

Almond  Cakes 

319.8  calories 

1  lb.  almonds  ground  2  tbs.  milk 

4  eggs  1  pinch  salt  (i  tsp.) 

Beat  eggs  light ;  add  salt,  milk,  and  almond  flour ;  bake  in  12 
flat  buttered  tins  in  a  moderate  oven  for  15  minutes. 

CoRNMEAL  Gruel 

100  calories 

2  tbs.  corn  meal  1  cup  water 

J  tsp.  salt 

Allow  water  to  boil,  mix  corn  meal  with  3  or  4  teaspoonfuls 
of  cold  water.  *  As  soon  as  water  begins  to  boil,  stir  briskly  until 
gruel  begins  to  thicken.  Then  place  on  a  cooler  part  of  the  stove, 
and  cook  gently  for  2  hours,  replacing  water  as  it  evaporates. 
Strain  through  a  coarse  sieve  if  it  lumps. 

Farina 

171  calories  {2  servings) 

3  tbs.  (1  oz.)  farina  J  cup  boiling  water 

J  cup  rich  milk  J  cup  cold  water 

J  tsp.  salt 

Mix  farina  into  a  paste  with  cold  water.  Stir  into  boiling  water, 
allow  to  cook  for  half  an  hour  (if  water  boils  out,  add  boiling 
water).  Add  milk,  and  place  the  saucepan  in  a  hot  water  bath 
(double  boiler) ;  allow  to  cook  half  an  hour  longer,  stirring  occa- 
sionally. 

Rice  (No.  1) 

99.4  calories 

2  tbs.  (1  oz.)  rice  1  pt.  boiling  water 

J  tsp.  salt 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    81 

Soak  rice  for  1  hour  in  cold  water.  Sprinkle  into  the  briskly 
boiling  water,  taking  care  not  to  stop  the  boil.  Allow  to  cook 
until  tender ;  test  by  pressing  a  grain  between  thumb  and  finger ; 
there  should  be  no  hard  center.  When  the  rice  is  done,  turn  it 
into  a  colander  and  allow  water  from  cold  faucet  to  run  over  it  to 
wash  off  surplus  starch.  Return  to  saucepan  ;  place  on  stove  where 
moisture  can  be  dried  out  of  the  rice  without  burning  it. 

Rice  (No.  2) 

217  calories  {2-3  servings) 

4  tbs.  rice  j  cup  water 

J  tsp.  salt  J  cup  milk 

Wash  rice  and  soak  it  in  cold  water  for  1  hour  (or  overnight). 
Place  in  an  earthenware  baking  dish,  cover  with  the  milk,  water 
and  salt.  Cover  and  set  in  the  oven ;  -allow  to  cook  until  all  of 
the  moisture  is  absorbed  (if  the  rice  is  not  done  by  the  time  the 
moisture  has  evaporated,  add  more  milk,  or  milk  and  water, 
and  continue  until  the  grains  are  tender).  If  the  given  amount  of 
moisture  is  not  absorbed  by  the  time  the  rice  is  tender,  drain  off 
the  surplus  and  return  the  dish  to  the  oven  for  a  few  moments. 
Each  grain  should  be  separate,  when  the  dish  is  prepared  correctly. 

Vegetables 

Baked  Potato  (White)   ^ 

1  potato  weighing  about  3  ounces;  scrub  well  with  a  brush; 
dry  and  slightly  grease  surface,  place  in  moderately  hot  oven  and 
bake  about  45  or  50  minutes.  (The  potato  should  feel  tender 
upon  pressure.)  When  done,  make  an  incision  of  1  inch  in  the 
skin  and  gently  press  out  the  steam ;  cover  closely  with  cloth  and 
keep  in  a  warm  place  until  ready  to  serve.  Put  1  teaspoonful 
(about  i  ounce)  of  butter  in  the  cut  and  serve  very  hot. 

Creamed  Potato 
\  tsp.  salt  2  tsp.  milk 

1  medium  size  potato  1  tsp.  butter 


82  DIETETICS  FOR  NURSES 

Pare  and  boil  potato  until  tender  when  pierced  with  a  fork; 
drain  off  the  water  and  return  the  saucepan  to  the  stove ;  shake 
the  pan  (to  prevent  burning)  until  the  potato  looks  dry;  mash 
with  fork  or  potato  ricer,  add  milk,  butter,  and  salt.  Beat  briskly 
until  creamy.     Serve  at  once  or  brown  in  oven. 

Potato  Stuffed  with  Meat 

155.2  calories 

1  potato  (baked)  1  tbs.  cold  chopped  beef 

J  tsp.  salt  1  tsp.  butter 

Dash  of  pepper 

Bake  potato,  split  in  half  and  remove  the  contents,  mix  with 
the  chopped  meat,  add  salt,  pepper,  and  butter ;  return  to  the  two 
halves,  set  in  oven  to  brown,  then  serve  at  once. 

Scalloped  Potatoes 

163.1  calories 

1  potato  \  cup  milk 

2  tsp.  butter 

Boil  potato,  not  quite  tender,  and  slice  in  moderately  thin 
slices ;  arrange  in  layer  in  an  individual  earthenware  baking  dish 
(ramekin),  add  butter  in  bits  between  layers,  pour  the  milk  over; 
set  dish  in  oven,  cover  and  bake  slowly  for  15  minutes,  until  most 
of  the  milk  is  absorbed  and  the  potatoes  are  nicely  browned  on 
top.  In  cases  where  the  patient  is  allowed  cheese,  2  teaspoon- 
fuls  may  be  sprinkled  between  the  layers,  giving  31  additional 
calories. 

Peas  ^ 

H9.2  calories 

J  cup  fresh  peas  1  tsp.  butter 

1  pt.  boiling  water  \  tsp.  salt 

'  Canned  peas  may  be  substituted  for  fresh  ones.  Fuel  value  62.8  calories, 
with  butter,  98.8  calories. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    83 

Add  salt  and  peas  to  boiling  water;  allow  to  cook  from  30 
to  60  minutes,  or  until  they  are  perfectly  tender,  drain  and 
add  butter  and  additional  salt  if  necessary,  or  1  tablespoonful 
of  cream  sauce.  In  gastro-intestinal  disorders  and  with  young 
children,  it  is  best  to  press  peas  through  sieve  or  remove  the 
indigestible  parts. 

String  Beans  ^ 

83,2  calories 

1  cupful  of  string  beans  (measured  after  the  strings  are  re- 
moved and  the  beans  cut  into  small  pieces) 

1  tsp.  butter  |  tsp.  salt 

Cover  with  boiling  water  and  cook  until  tender,  drain,  and  serve 
hot. 

Spinach 
94  calories  {About  2  servings  —  8  oz.) 

2  qts.  spinach  J  tsp.  salt 

2  tsp.  butter 

Wash  thoroughly  through  about  ten  waters,  until  spinach  is 
entirely  free  from  grit,  remove  the  tough  stems,  lift  the  spinach 
from  water  and  place  in  a  saucepan  without  additional  water, 
sprinkle  over  with  salt,  cover  saucepan  and  cook  until  tender 
(requires  about  15  minutes).  Cut  very  fine  with  sharp  knife,  or 
press  through  sieve,  add  butter  and  serve  hot. 

Carrots  (with  Cream  Sauce  or  Butter) 
130.3  calories  —  8O.4  calories 

Carrots,  about  ^  cupful  after  they  are  cut  in  cubes,  or  3|  ounces. 
Serve  with  2  tablespoonfuls  of  cream  sauce,  or  with  2  teaspoonfuls 
of  butter  and  a  little  salt  and  pepper.  Scrub  carrots  and  scrape 
off  the  skins;    cut  into  slices  or  cubes,  drop  into  slightly  salted 

*  a  one-inch  piece  of  salt  pork  may  be  cooked  with  the  beans  and  removed 
before  serving  in  place  of  the  butter. 


84  DIETETICS  FOR  NURSES 

boiling  water  and  cook  until  tender;    drain  and  add  butter  or 
cream  sauce. 

Whole  Tomato  Stuffed  with  Rice 
151.4  calories 

1  medium  size  tomato  1  tsp.  butter 

2  tbs.  rice  (uncooked)  Dash  of  pepper  and  salt 

Remove  the  center  from  the  tomato,  dust  the  inside  with  salt 
and  a  very  little  pepper  and  set  aside.  Boil  the  rice,  when  about 
half  done  (10  minutes)  add  the  tomato  pulp,  from  center  of  tomato. 
Cook  10  minutes  longer,  drain  the  water  from  the  rice,  add  the 
butter,  salt,  and  a  little  pepper.  Fill  the  center  of  tomato  with 
rice.  Set  the  tomato  upon  a  greased  paper  and  bake  in  a  moder- 
ate oven  for  20  minutes. 

Broiled  Tomatoes 

385  calories 

Slice  1  tomato  in  three  or  four     1    slice   of   bread    (round   pre- 

slices  ferred) 

1  tbs.  butter  \  cup  of  cracker  crumbs 

Salt  and  pepper 

Heat  broiler  or  frying-pan  very  hot,  grease  lightly;  season 
crumbs  with  salt  and  pepper;  dip  slices  of  tomato  in  cracker 
crumbs,  covering  both  sides  well,  and  place  upon  the  broiler; 
when  one  side  is  browned,  turn  over  carefully,  to  prevent  break- 
ing, and  allow  the  other  side  to  brown.  Lift  the  broiler  to  the 
lower  half  of  the  oven  and  let  the  tomatoes  cook  gently  for  10 
minutes.  Place  bits  of  butter  upon  each  slice,  then  arrange  these 
on  the  buttered  toast. 

Stewed  Tomato  on  Toast 

170  calories 

\  cup  canned  tomatoes  1  slice  bread 

§  cup  water  2  tsp.  butter 

\  tsp.  salt 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    85 

Pour  tomatoes  and  water  in  a  saucepan  and  allow  to  cook 

slowly  for  20  minutes,  add  salt  and  a  dash  of  pepper.     Toast  and 

butter  the  bread,  pour  the  cooked  tomatoes  over  it  and  serve  at 

once. 

To  Broil  Squab  or  Quail 

1  quail  on  toasty  Jfl9  calories 

1  squab,  J^  calories 

Split  down  the  back  and  place  on  the  broiler,  cut  surface  upper- 
most. Or  place  upon  a  hot  pan,  cut  surface  next  to  the  hot  sur- 
face so  that  the  cut  side  may  sear  quickly,  thus  keeping  in  the 
juices  instead  of  having  them  wasted  in  the  pan  by  slow  cooking. 
The  process  requires  about  15  to  20  minutes.  Serve  on  toast, 
with  butter,  pepper  and  salt. 

Quail  or  squab  cooked  inside  the  stove  is  often  more  palatable 
than  that  cooked  on  a  broiler.  The  bird  is  split  as  for  broiling, 
and  placed  in  a  small  pan  just  large  enough  to  hold  it ;  a  strip  of 
bacon  pinned  about  the  breast ;  add  1  tablespoonf ul  of  butter  in 
bits,  dust  the  cut  surface  first  with  salt  and  pepper,  then  with 
flour ;  add  J  cup  of  hot  water.  Turn  another  pan  over  the  bird 
(it  must  fit  closely  to  keep  in  the  steam),  place  inside  the  oven  and 
cook  about  10  minutes ;  turn  the  bird  over  and  cook  10  minutes 
longer.  Lift  the  bird  from  the  pan  and  place  it  where  it  will  keep 
hot,  add  a  tablespoonful  more  water  and  a  teaspoonful  more  flour 
to  the  gravy  in  the  pan,  stir  briskly  to  remove  any  lumps,  remove 
bacon  and  place  the  bird  upon  a  slice  of  nicely  browned  toast ;  pour 
over  it  the  gravy,  garnish  with  a  sprig  of  parsley,  and  serve  at  once. 

When  steak  or  chops  are  served,  parsley  or  sliced  lemon  may 
be  used  as  garnishes.  Chops  may  be  served  garnished  with  green 
peas,  and  the  beefsteak  served  with  potatoes  cooked  in  any  way ; 
all  meats  should  be  served  very  hot.     It  is  best  to  cover  with 

a  plate. 

Bacon 

2  slices,  100  calories 

Select  bacon  with  a  strip  of  lean  and  fat,  slice  thin  and  place 
upon  the  broiler,  place  a  pan  beneath  the  broiler  to  catch  the 


86  DIETETICS  FOR  NURSES 

drippings  and  prevent  the  bacon  from  catching  fire.  Cook  until 
nicely  brown  on  one  side  and  turn,  repeating  the  process.  Serve 
alone  or  with  liver,  beefsteak,  or  chops. 

Chicken  (One  Half) 

ji38.4  calories 

Split  small  chicken  (broiler)  down  the  back,  flatten  the  breast 
bone  with  knife  before  placing  upon  the  broiler,  proceed  as  in 
broiling  birds,  allowing  from  25  to  30  minutes  for  the  process. 
Chicken  is  very  palatable  and  dainty  if  cooked  after  the  manner 
described  in  cooking  quail  and  squab  inside  the  stove.  The 
process  is  called  smothering.  Serve  upon  buttered  toast,  garnished 
with  parsley. 

Birds  or  Chicken  a  la  Bain  Marie 
1074  calories;  1  serving,  134  calories 

1  small  chicken,  or  bird  1  tbs.  parsley 

2  tbs.  butter  Salt  and  pepper 

Split  birds  or  chicken  as  for  broiling,  place  one  half  in  a  chafing 
dish  or  double  boiler  (bain-marie),  dot  the  cut  surface  with  butter, 
sprinkle  over  it  the  parsley,  dust  with  pepper  and  salt ;  place  the 
other  half  of  the  chicken  or  bird  on  top  of  this,  add  the  rest  of  the 
butter,  dust  with  salt  and  pepper,  cover,  and  place  the  pan  over 
the  hot  water  pan ;  allow  to  steam  for  about  1  hour,  lift  from  hot 
water  pan  and  place  in  oven  or  under  the  flames  to  brown  lightly. 
Serve  on  buttered  toast. 

Roasted  or  Baked  Chicken,  Turkey,  or  Duck^ 

408. 6  calories 

Draw  the  fowl  and  wash  thoroughly  inside  and  out.  (If  it  is 
purchased  from  the  market,  it  is  well  to  wash  the  inside  with  soda 
water  to  remove  any  stale  flavor  that  may  be  present.) 

8  3^  ounces  :  chicken,  224  calories  ;  turkey,  284.9  calories  ;  duck,  about  257.3  calories. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    87 

Make  a  dressing  from  one-third  of  a  small  loaf  of  bread  broken 
into  small  pieces ;  J  cup  chopped  celery,  1  tablespoonful  of  chopped 
parsley,  1  tablespoonful  of  butter  and  one  egg  beaten  lightly. 
Stuff  the  cavity  with  dressing,  sew  up  the  opening  and  place  in 
dripping  pan.  Place  pan  under  the  flame  for  a  few  minutes  to 
brown,  unless  a  regular  roasting  pan  (savory  roaster)  is  used; 
allow  to  bake  from  45  minutes  to  an  hour  and  a  half  for  chicken 
and  duck  according  to  the  size,  and  from  an  hour  and  a  half  to 
three  hours  for  turkey  according  to  size.  A  cupful  of  boiling 
water  may  be  poured  into  the  pan  in  which  the  chicken,  etc.,  is 
being  roasted  and  flour  may  be  sifted  over  the  top ;  dust  with  salt 
and  pepper.  When  an  ordinary  pan  is  used  for  baking,  the  fowl 
will  require  frequent  basting  to  keep  it  moist  and  tender.  Just 
as  the  baking  is  finished,  more  butter,  flour,  and  seasoning  may  be 
added,  with  a  cup  or  more  of  boiling  water  to  make  additional 
gravy. 

Sweetbreads 

287.5  to  208.8  calories 

i  set  of  sweetbreads  |  tsp.  of  salt 

1  lemon  \  tsp.  of  pepper  (red) 

Wash  sweetbreads  carefully  and  allow  to  stand  1  hour  in  ice 
water,  allow  the  water  containing  the  lemon  juice,  salt  and  pepper 
to  come  to  a  boil  and  drop  in  the  sweetbreads,  cook  for  15  or  20 
minutes  or  until  tender  when  pierced  with  fork.  Remove  from 
hot  water  and  pour  ice  water  over  them  to  blanch.  Serve  either 
in  cream  sauce  or  split  in  half  and  broil  upon  a  slightly  greased 
broiler  until  light  browTi ;  season  with  a  dash  of  salt  and  pepper 
(about  i  of  a  teaspoon  of  pepper  mixed)  and  1  teaspoon  of  butter, 
serve  on  toast  garnished  with  parsley. 

Broiled  Fish 

3  minces,  172.9  calories 

Split  down  the  back,  and  broil  as  beefsteak.  Fish  does  not 
require  more  than  from  10  to  15  minutes  to  broil  unless  very  large. 
Serve  with  teaspoonful  of  parsley  and  butter. 


88  DIETETICS  FOR  NURSES 

Fish  Steaks,  Stuffed  with  Oysters 

3  ounces,  168.3  calories 
Halibut,  trout,  or  any  good  baking  fish,  235.8  calories 

2  slices  of  fish  1  cup  bread  crumbs 

1-1 J  in.  thick  4  tbs.  butter 

1  doz.  oysters  Salt  and  pepper 

Lay  fish  for  one  hour  in  a  French  dressing  made  from  J  cup  of 
oil,  \  cup  of  vinegar,  salt  and  pepper ;  drain  and  place  upon  slices 
of  bacon,  placed  upon  a  fish  sheet  or  dripping  pan.  Dip  oysters 
first  in  melted  butter,  then  in  bread  crumbs,  and  place  upon  the 
slice  of  fish,  adjust  second  slice  above,  cover  top  with  bread 
crumbs,  dot  with  butter  and  bake  30  to  45  minutes  in  moderate 
oven.    Serve  with  hollandaise  sauce. 

Broiled  Oysters 
182  calories 

6  oysters       '  1  slice  toast 

2  t^p.  butter  Salt  and  pepper  to  taste 

Grease  broiler  or  hot  frying  pan  slightly,  place  oysters  upon  the 
heated  surface  and  place  under  the  flame  or  on  top  of  the  stove ; 
cook  until  the  edges  curl  (2  to  3  minutes),  lift  to  a  hot  dish  contain- 
ing the  butter,  place  toast  upon  small  plate  (toast  and  plate  must 
be  hot),  dispose  the  oysters  upon  the  toast,  and  pour  over  them 
the  butter. 

Lobster  or  Crab 

1  serving  lobster,  157  calories 
1  serving  crab,  154  calories 

1  lobster,  or  1  tbs.  butter 

1  crab  2  tsp.  butter 

2  tbs.  bread  crumbs  \  tsp.  salt 

i  tsp.  pepper   • 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    89 

Boil  lobster  or  crab  until  bright  red,  lift  from  boiling  water. 

Split  lobster  down  the  back  and  carefully  remove  cord,  gall 
sack,  and  sand  bag  before  broiling  or  serving.  Serve  with 
melted  butter. 

Pick  meat  from  shell  of  crab,  and  mix  with  salt,  pepper  and 
butter.  Stuff  into  shell.  Cover  top  with  bread  crumbs,  and 
brown  in  the  oven. 

HOLLANDAISE   SaUCE 

161.6  calories 
1  tablespoonful,  26.9  calories 

1  egg  (yolk  only)  1  tbs.  butter 

2  tbs.  lemon  juice  J  cup  boiling  water 

Salt  and  pepper  to  please 

Beat  egg  yolk  with  lemon  juice;  add  one-half  the  butter; 
place  in  double  boiler  over  hot  (not  boiling)  water.  Stir  until  it 
begins  to  thicken  and  add  remainder  of  butter ;  stir  in  boiling 
water,  cook  until  of  the  consistency  of  boiled  custard. 

The  Cooking  of  Meats 

Veal  Cutlets 

2  cutlets y  203  calories 

Dip  cutlets  first  in  egg  (mix  one  yolk  with  1  tablespoonful  of 
water)  then  in  bread  crumbs;  pan  broil  (grease  the  frying  pan 
slightly),  or  broil  under  the  flame  as  directed  in  cooking  beefsteak. 
Veal  cutlets  may  be  served  plain,  or  with  tomato  sauce. 

Cutlets  or  chops  may  be  cooked  in  paper  bags  if  desired.  Wrap 
the  chop  in  a  thin  slice  of  bacon,  grease  the  paper  (a  piece  of  heavy 
brown  paper),  place  the  chop  inside  and  secure  the  ends  with 
paper  clips  or  pins ;  place  in  a  pan  and  cook  in  the  oven,  or  under 
the  flame.  It  is  wise  to  slip  the  bag  containing  the  chop  inside  of 
another  bag ;  in  this  way  the  meat  will  not  taste  of  scorched  paper 
if  the  outer  bag  should  burn. 


90  DIETETICS  FOR  NURSES 

Beefsteak 
266.3  calories 

3  inches  long  by  2  inches  wide  by  1^  inches  thick  (weighing  abcmt 
3  ounces). 

Wipe  steak  off  with  a  wet  cloth  and  dry  before  cooking. 
Slightly  grease  the  broiler  and  place  under  the  flame,  count 
ten  as  the  clock  ticks  and  turn  the  steak  over,  count  ten  again 
and  again  turn ;  continue  this  for  about  3  minutes  or  until  the 
steak  is  seared  upon  both  sides,  lift  the  broiler  to  a  lower  part 
of  the  oven  and  continue  the  cooking  for  5  to  8  minutes ;  run  a 
sharp-pointed  knife  between  the  meat  and  the  bone  (if  the  steak 
is  a  porterhouse  or  sirloin),  and  if  the  flesh  is  red,  continue  the 
cooking  a  minute  or  more.  If  it  is  pink,  lift  to  a  hot  plate,  place 
1  teaspoonful  of  butter  upon  it,  dust  the  surface  with  salt  and 
pepper  and  serve  hot.  Pan  broiling  is  done  on  the  top  of  the 
stove  in  a  flat  frying  pan.  Wipe  the  pan  with  a  clean  wet  cloth, 
place  upon  the  stove  and  heat  piping  hot,  and  place  the  steak 
(without  greasing  the  pan)  upon  the  hot  surface.  Proceed  as  in 
broiling  under  the  flame.  After  the  first  3  minutes  of  cooking, 
place  the  pan  on  a  cooler  part  of  the  stove  to  finish  the  cooking. 

Lamb  or  Mutton  Chops 

2  chops,  339  calories 

1  to  2  inches  thick  will  require  from  10  to  15  minutes'  cooking. 
Scrape  the  bone  clean  and  wrap  in  paper  or  dough  to  prevent  the 
bone  from  becoming  charred.     Proceed  as  in  cooking  beefsteak. 

Salads 

Tomato  1.  Peel  tomato  cut  almost  through  to  form  six  parts 
like  a  flower ;  place  on  lettuce  leaf  and  serve  with  French  dressing 
or  mayonnaise;  142.8  calories  with  1  tablespoonful  of  French 
dressing ;  49  calories  with  1  teaspoonful  of  mayonnaise. 

Tomato  2.  Peel  tomato  and  remove  the  seeds  and  pulp;  fill 
hollow  with  chopped  celery,  mixed  with  mayonnaise.     1 14  calories. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    91 

Lettuce,  chicory,  romaine,  and  cress  must  be  washed  until 
thoroughly  clean  in  cold  water;  discard  all  tough  leaves  and 
fibers ;  lift  from  water,  shake  off  water ;  wrap  in  towel  and  place 
on  ice  to  become  crisp.  If  this  is  impossible,  leave  in  cold  water 
until  ready  to  serve,  then  dry  the  leaves  on  a  soft  towel.  Serve 
with  French  dressing  or  mayonnaise. 

Cucumber.  Peel,  slice,  and  stand  in  cold  water  1  hour  before 
serving;  dry,  dress  with  a  teaspoonful  vinegar,  1  of  oil,  a  little 
salt  and  pepper.     1  serving,  50  calories. 

Fruit  Salads  (6  servings).     3  grapefruit,  1  cup  celery. 

Method  I.  Remove  skin  and  seed  from  grapefruit  and  break 
into  several  pieces.  Cut  celery,  mix  with  French  dressing.  Serve 
in  baskets  made  from  grapefruit  shells;  garnish  with  rings  of 
green  pepper.     1  serving,  130.2  calories. 

Method  II  (6  servings).  Peel  5  oranges,  remove  inner  skin  and 
seed,  break  into  small  pieces ;  do  not  bruise  fruit,  allow  to  stand 
20  minutes  in  French  dressing ;  drain,  place  on  lettuce  leaf,  or  in 
half  of  orange  skin,  and  pour  over  it  fresh  French  dressing; 
garnish  with  rings  of  green  pepper.     1  serving,  202  calories. 

French  Dressing 

136.8  calories 

1  tbs.  oil  i  tbs.  vinegar,  or  lemon  juice 

Dash  of  pepper  and  paprika 

Have  all  ingredients  cold ;  mix  salt  and  pepper  together ;  stir 
in  the  oil,  add  vinegar  or  lemon  juice  slowly,  beating  briskly  to 
form  an  emulsion ;   use  immediately  or  ingredients  will  separate. 

Use  as  little  salt  as  possible  in  nephritic  conditions. 

Mayonnaise 

2100  calories 
1  teaspoonful,  29.4  calories 

1  egg  (yolk  only)  J  tsp.  mustard  (dry) 

2  tbs.  lemon  juice  (or  vinegar)  Dash  red  pepper 
J  tsp.  salt  1  cup  olive  oil 


92  DIETETICS  FOR  NURSES 

Method  of  Mixture :  Mix  dry  ingredients  with  yolk  of  egg 
thoroughly;  add  all  the  acid  (use  Dover  beater).  Now  add,  one 
teaspoonful  at  a  time,  the  olive  oil;  beat  continually  until  the 
mixture  thickens  (after  8  teaspoons  of  oil  have  been  added) .  Put 
in  oil  by  tablespoonfuls  until  all  is  incorporated.  This  method 
shortens  the  time  of  making  at  least  one  half,  and  the  dressing 
rarely  curdles  as  it  often  does  in  the  old  methods. 

Whipped  cream  may  be  added  to  dressing  before  serving. 
Mayonnaise  will  keep  if  placed  in  a  cool  place,  and  the  above 
quantities  are  more  easily  handled  than  smaller  amounts. 


Desserts 

Baked  Custard 

238  calories 

1  egg  I  cup  milk 

1  tbs.  sugar  A  few  drops  of  vanilla 

Beat  Ggg  and  sugar  together,  stir  into  the  milk,  grease  custard 
cup  with  butter,  pour  in  the  mixture.  Set  cup  on  several  layers 
of  paper  in  a  deep  pan,  surround  with  hot  water  (to  about  half  its 
depth).  Set  pan  in  moderate  oven  and- allow  to  cook  slowly  until 
custard  is  firm  in  the  center.  It  ma}^  be  served  hot  or  chilled 
and  turned  out,  with  a  tablespoonful  of  whipped  cream  on  top. 

Care  must  be  taken  not  to  allow  the  oven  to  get  hot,  or  the  egg 
will  coagulate,  making  a  watery,  unpalatable,  and  indigestible 
mixture. 

Caramel  Custard 

298  calories 

Caramel  custard  is  made  exactly  the  same  as  baked  custard, 
except  that  the  cup  is  lined  with  a  caramel  made  as  follows :  In 
a  small  frying  pan,  place  1  tablespoonful  of  sugar,  place  on  the 
stove  and  stir  constantly  until  it  melts  and  turns  a  golden  brown 
(do  not  allow  to  burn).     Fold  a  cloth  about  the  custard  cup  and 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    93 

pour  in  the  caramel,  moving  the  cup  about  until  the  sides  and 
bottom  are  well  coated.  Pour  in  the  custard  mixture  and  proceed 
as  in  baked  custard. 

Soft  Custard 
^1,8  calories 

1  egg  (or  2  yolks)  1  cup  milk 

1  tbs.  sugar  A  few  drops  of  vanilla 

Heat  milk  in  double  boiler.  Beat  egg  and  sugar  together. 
Wlien  milk  has  reached  the  scalding  point  (small  bubbles  form 
around  the  edge  of  the  saucepan),  stir  in  the  egg.  Care  must  be 
taken  not  to  allow  the  water  under  the  saucepan  to  become  too 
hot,  as  the  custard  will  curdle  if  the  egg  is  cooked  at  too  high  a 
degree  of  temperature.  The  custard  must  be  stirred  constantly 
in  the  beginning  until  it  begins  to  thicken,  then  several  times  a 
minute  until  it  is  of  the  desired  consistency  and  the  raw  taste  is 
cooked  out  of  the  egg.  This  mixture  is  done  when  it  will  form  a 
coating  upon  the  spoon.  Serve  with  whipped  cream  on  top  (57 
calories  extra  with  cream). 

Snow  Balls 

^54.7  calories 

J  cup  rice  1  cup  milk 

J  tsp.  salt 

Place  in  a  double  boiler  and  cook  without  stirring  until  milk  is 
absorbed  and  rice  is  tender.  Then  either  pack  in  egg  cups  (wet 
first  so  that  rice  will  slip  out  without  breaking),  or  take  a  square 
of  cheesecloth  8  inches  square,  dust  *vith  flour  and  place  about 
4  tablespoons  of  the  cooked  rice  in  center,  draw  the  corners  together 
and  tie  firmly  into  a  ball.  Set  the  ball  in  a  steamer  and  steam 
1  hour.  Remove  the  cloth  gently  to  prevent  breaking  the  balls. 
They  may  be  served  with  custard  as  a  dessert,  or  as  a  vegetable 
with  tomato  dressing. 


94  DIETETICS  FOR  NURSES 

Baked  Tapioca 

2  servings,  513  calories 

1  cup  milk  (scalded)  3  tbs.  sugar 

2  egg  yolks  6  dates 

2  tbs.  minute  tapioca 

Beat  sugar  and  egg  together,  stir  in  the  tapioca  and  dates,  cut 
into  small  pieces.  (The  dates  may  be  omitted,  if  desired.)  Pour 
mixture  into  custard  cups  and  bake  slowly  (as  rice  custard)  until 
the  tapioca  is  clear  and  the  custard  is  fairly  firm  in  center. 

Orange  Tapioca 
2  servings,  519.7  calories 

\  cup  milk  2  tbs.  minute  tapioca 

I  cup  orange  juice  2  egg  yolks 

\  cup  sugar  6  drops  orange  extract 

Mix  and  bake  as  directed  in  plain  baked  tapioca  custard.  Any 
other  fruit  juice  may  be  substituted  for  the  orange,  raspberry, 
pineapple,  or  grape  juice. 

Apple  Tapioca  Pudding 

512  calories 

1  apple  (pared  and  cored)  2  tbs.  sugar 

1  egg  1|  tbs.  tapioca 

I  cup  milk  \  tsp.  nutmeg 

Beat  egg  and  sugar  together.  Heat  milk  in  double  boiler  and 
add  egg  when  milk  is  scalding  hot.  Stir  in  tapioca.  Cook  20 
minutes.  Place  apple  in  cup  a  little  larger  than  the  apple  and 
pour  the  tapioca  custard  over  the  apple.  Cover  the  cup  and  bake 
30  minutes  in  a  moderate  oven. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    95 

Rice  Custard 
353.4  calories 

1  tbs.  raw  rice,  broiled  J  cup  milk 

1  egg  1  tbs.  sugar 

1  tbs.  whipped  cream  1  doz.  raisins  if  desired 

A  few  drops  of  vanilla 

Beat  sugar  and  egg  together.  Stir  into  the  milk,  stir  in  the  rice 
and  flavor  (add  raisins  if  desired  —  29  calories).  Grease  custard 
cup  and  fill  with  the  mixture.  Bake  slowly  (in  a  pan  of  hot  water) 
until  custard  is  firm  in  center.    Serve  with  whipped  cream. 

Orange  Rice  Custard 
2  servings,  399.2  calories 

2  oz.  orange  juice  2  egg  yolks 

2  tbs.  sugar  J  cup  boiled  rice  (or 

J  cup  milk  J  cup  uncooked) 

Beat  egg,  sugar,  and  orange  juice  together.  Mix  milk  with  rice 
and  stir  the  two  mixtures  together.  Bake  as  directed  in  plain 
rice  custard. 

Tapioca  Custard 

317  calories 

1  cup  milk  1  egg 

2  tbs.  tapioca  (minute  tapioca)  3  tbs.  sugar 

Flavor  with  vanilla  or  nutmeg,  or  -|  square  chocolate  grated. 
Scald  milk.  Boil  tapioca  in  hot  water  until  transparent  like  jelly, 
using  one  cupful  of  boiling  water.  (If  tapioca  does  not  absorb 
all  of  the  water,  pour  off  the  surplus.)  Beat  egg  and  sugar  to- 
gether and  add  with  the  milk  to  the  tapioca.  Pour  into  a  double 
boiler,  and  cook  until  the  raw  egg  flavor  has  disappeared.  Flavor 
as  desired.    43  calories  extra  with  chocolate. 


96  DIETETICS  FOR  NURSES 

Foamy  Sauce 
739  to  746  calories 

J  cup  powdered  sugar  1  tbs.  sherry  wine  or 

I  cup  butter  1  tbs.  hot  milk 

i  one  egg  yolk  and  1  whole  egg  white  J  tsp.  vanilla 

Cream  butter  and  sugar  (powdered  sugar  must  be  used  in  this 
recipe).  Stir  in  the  well-beaten  yolk,  add  sherry  and  pour  into 
saucepan  over  hot  water ;  stir  until  thick  and  creamy,  lift  from 
hot  water  and  cool  as  quickly  as  possible,  fold  in  the  stiffly  beaten 
white  of  egg  and  serve  over  pudding  at  once. 

Sauce  for  Puddings 

495  calories  with  sherry;  549  calories  with  fruit  juice 

6  sermngs;  1  serving f  91.5  calories 

1  egg  I  glass  orange 

§  cup  powdered  sugar  1  tbs.  lemon  juice 

1  wineglass  sherry  wine  or  whisky,  or  1  tsp.  hot  milk 

Beat  yolk  and  white  of  egg  separately,  add  sugar  to  yolk  and 
beat  until  creamy,  add  wine  or  fruit  juice,  fold  in  the  egg  white 
and  add  the  hot  milk  last ;  serve  at  once. 

Nut  Charlotte 

496  calories  without  wine ;  510  calories  with  wine 

Two  servings 

i  cup  40%  cream  8  pecan  or  walnut  meats 

2  tbs.  sugar  \  tsp.  vanilla  or 

1  tbs.  sherry  wine 

Dissolve  sugar  in  the  cream  and  beat  solid,  add  flavoring  or 
sherry  and  nuts. 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    97 

Floating  Island 

825  calories 

1  egg  and  1  extra  yolk  2  lady  fingers 

1  cup  milk  Few  drops  vanilla 

1  tbs.  sugar 

Make  soft  custard,  using  the  two  yolks  (no  white).  Chill 
custard  thoroughly.  Line  individual. ice  cream  cup  with  the  lady 
fingers ;  pour  the  custard  over.  Beat  the  white  of  egg  and  place 
on  top.  Serve  at  once.  The  lady  fingers  may  be  dipped  in  sherry 
wine  if  desired,  using  about  2  tablespoonfuls  of  wine.  (26  calories 
extra.) 

Brown  Betty 

2  servings,  466  calories 

2  slices  bread  .  2  tbs.  sugar 

1  large  tart  apple  (or  1  tbs.  butter 

J  cup  blueberries  may  be  substituted  J  tsp.  nutmeg  or  cinnamon 
for  the  apple) 

Toast  bread  and  break  into  small  pieces,  line  the  bottom  of  the 
individual  baking  dish  with  toast  bits,  cover  with  a  layer  of  apple 
or  berries,  sprinkle  with  sugar  and  nutmeg  or  cinnamon,  add  butter 
in  bits  over  this,  continue  the  process  until  the  dish  is  filled,  place 
bits  of  butter  on  top  of  the  last  layer  of  toast  and  set  dish  in  oven ; 
bake  about  20  minutes  in  a  slow  oven ;  serve  with  whipped  cream 
or  hard  sauce. 

Hard  Sauce 

228.8  calories 

1  tbs.  butter  ^  egg  white  may  be  added  if  desired 

2  tbs.  sugar  §  tsp.  vanilla,  or  |  tsp.  nutmeg 

Cream  butter  and  sugar  together  until  there  are  no  lumps  or 
grains  in  mixture.  Beat  the  egg  white  stiff  and  fold  into  the 
sugar  and  butter  mixture.     Flavor. 


98  DIETETICS  FOR  NURSES 

Orange  Charlotte 
657  calories 

J  cup  of  orange  jelly  mixture  (see  directions  for  making  under 
jellies),  I  cup  double  cream,  1  tbs.  sugar  (the  above  quantity  will 
require  about  2  tsp.  of  granulated  gelatine). 

Pour  jelly  mixture  into  a  bowl  and  surround  with  cracked  ice ; 
when  it  begins  to  stiffen,  fold  in  the  stiffly  beaten  cream. 

Pour  into  molds  or  ice  cream  glasses  and  set  aside  in  the  ice-box 
to  become  set. 

Snow  Pudding 
428  calories  for  orange  pudding 

Orange,  lemon,  grape  juice,  or  pineapple  may  be  used  in  prepar- 
ing this  pudding. 

J  cup  fruit  juice  }  cup  sugar 

2  tsp.  gelatine  1  egg  white  and 

1  tbs.  cold  water  J  cup  soft  custard 

Make  jelly  mixture  as  already  directed  and  place  the  bowl  in  a 
pan  of  cracked  ice ;  when  the  mixture  begins  to  stiffen,  fold  in  the 
well-beaten  egg  white  (beat  it  in  with  an  egg  beater).  Pour  the 
mixture  into  a  mold  or  individual  glasses  and  set  aside  on  ice  to 
become  set.  When  ready  to  serve,  unmold  and  pour  on  the  soft 
cold  custard. 

Prune  or  Prune  Fig  Whip 

1844  or  244.9  calories 

6  prunes  or  4  prunes  and  1  fig  1  egg  white 

2  tbs.  sugar 

Cook  the  prunes  and  figs  in  sufficient  water  to  cover  them  until 
they  are  perfectly  soft,  press  through  a  sieve,  add  sugar,  chill 
thoroughly,  and  fold  in  the  stiffly  beaten  egg  white.     The  above 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    99 

mixture  may  be  put  In  individual  cups  and  baked  in  a  slow  oven 
(in  a  pan  surrounded  with  hot  water)  until  they  are  firm  in  the 
center  and  a  light  brown.    Serve  with  or  without  whipped  cream. 

Sponge  Pudding 

760  calories 

2  tbs.  sugar  2  tbs.  butter 

J  cup  flour  1  cup  milk 

2  eggs  i  tsp.  vanilla 

Sift  flour  and  sugar  together  and  make  into  a  thin  paste  with 
part  of  the  milk,  heat  the  remainder  of  the  milk  and  stir  in  the 
flour  paste.  When  the  mixture  is  thick  and  smooth,  stir  in  the 
butter,  then  the  beaten  yolks  and  last,  the  whites  (well  beaten) 
are  folded  in.  The  mixture  is  now  turned  into  a  baking  dish  and 
baked  (in  a  pan  of  hot  water  as  any  other  custard)  until  it  is  firm 
in  the  center  and  well  puffed  up  and  brown.  Serve  with  foamy 
sauce. 

Jellies 

1  tablespoonful  cold  water  to  3  teaspoonfuls  granulated  gelatine 
used  in  making  the  following  jellies. 

Lemon 
160.9  calories 

\  cup  boiling  water  |  lemon,  or  2  tbs.  juice  and 

2  tbs.  sugar  (more  if  desired)  ^  rind  sliced  thin 

Orange 

25S.2  calories 

1  cup  boiling  water  3  tbs.  sugar 

6  tbs.  lemon  juice  2  drops  orange  extract 

J  cup  orange  juice 


100  DIETETICS  FOR  NURSES 

Grape  Juice 

SI  5. 4  calories 
\  cup  boiling  water  1  tbs.  lemon  juice 

I  cup  boiling  grape  juice  3  tbs.  sugar 

Wine  • 

74  calories 

\  cup  boiling  water  1  tsp.  lemon  juice  and  the  yellow 

3  tbs.  sherry  wine  rind  from  \  lemon 

1-inch  piece  of  cinnamon         3  tbs.  sugar 

Method  for  Fruit  Jellies 

Soak  gelatine  in  cold  water  about  2  or  3  minutes,  then  pour  over 
it  the  boiling  liquid;  add  sugar  and  fruit  juice;  strain  through 
cloth  into  wet  molds.  Set  in  cold  place  to  stiffen ;  when  firm, 
unmold.  Serve  with  whipped  cream,  or  pour  liquid  into  baskets 
made  from  oranges  or  grapefruit  hollowed  out  and  the  edges 
scalloped,  or  pour  into  shallow  pans,  and  cut  in  J-inch  blocks 
when  firm,  and  serve  on  a  bed  of  whipped  cream. 

Method  for  Wine  Jelly 

Put  water,  wine,  lemon  juice,  peel,  cinnamon,  and  sugar  into  a 
saucepan,  allow  to  boil  5  minutes,  pour  over  gelatine  (which  has 
been  soaked  in  cold  water).  If  jelly  looks  cloudy  return  to  sauce- 
pan, and  add  |  egg  white  beaten  stiff,  allow  to  boil  1  minute, 
stirring  constantly,  and  strain  into  mold.  Serve  with  whipped 
cream. 

Water  Ices 

( Two  servings) 
Lemon 

261.8  calories 
2  lemons  (juice  only)  1  egg  white 

J  cup  sugar  1  cup  water 


FORMULAS  FOR  PREPARATION  OF  F^OOD:  FOIi  S ^jGiC    XBl 

Orange 

3774  calories 

J  cup  orange  juice  1  cup  water 

1  lemon  J  tsp.  orange  extract 

I  cup  sugar  1  egg  white 

Grape  Juice 

358.7  calories 

i  cup  grape  juice  J  cup  sugar 

1  tbs.  lemon  juice  1  egg  white 

Method  of  Mixture 

Mix  sugar  and  water  and  boil  to  a  rich  sirup  (about  15  minutes), 
cool,  and  add  fruit  juice  (and  extract  when  it  is  used).  Pour  into 
freezer  and  surround  with  a  mixture  of  1  part  salt  and  two  parts 
ice.  When  sherbet  is  about  half  frozen,  stir  in  the  stiffly  beaten 
egg  white  and  continue  the  freezing  until  mixture  is  hard.  In 
diseases  where  it  is  found  inadvisable  to  give  albumen,  1  teaspoon- 
ful  of  gelatine  may  be  substituted. 

Apricot 
321  calories 

I  cup  apricot  puree  j  cup  sugar 

1  cup  water  1  tsp.  granulated  gelatine 

1  lemon  (juice  only) 

Make  sirup  of  water  and  sugar,  soak  gelatine  in  a  little  cold 
water  and  add  to  the  hot  sirup;  press  apricots  through  a  sieve 
and  add  to  the  sirup  as  soon  as  it  is  cool ;  freeze  as  directed  in 
other  ices. 

Strawberry 

282.8  calories 

1  cup  fruit  juice  i  cup  sugar 


I6a^^^}>  DIETETICS  FOR  NURSES 

Raspberry 

296  calories 

Juice  of  1  lemon  and  1  egg  white.    Proceed  as  in  other  ices.   * 

Currant 

604.9  calories 

1  cup  fresh  currants  J  cup  sugar 

1  cup  water  1  tbs.  lemon  juice 

Wash  currants  carefully  and  place  in  a  saucepan  on  a  warm 
but  not  hot  part  of  the  stove,  allow  to  heat  gently  until  the  cur- 
rants are  soft,  press  through  a  cloth,  and  add  the  water  and  sugar ; 
stir  until  dissolved  (or  make  a  sirup  of  the  water  and  sugar  and 
add  the  currant  juice  and  lemon  and  freeze  as  directed  in  other 
ices).    The  Qgg  white  may  be  added  if  desired. 

Junket 

Plain,  Coffee,  Egg,  Chocolate,  or  Cocoa  Junket 

Plain,  210,8  calories 

f  cup  milk  J  tsp.  vanilla  extract  or  a  grat- 

I  junket  tablet  ing  of  nutmeg 

1  tbs.  sugar 

Heat  milk  to  100°  F.  Add  junket  tablet  dissolved  in  1  tbs. 
cold  water.  Mix  in  sugar  and  flavoring,  and  pour  into  molds 
to  jelly.     When  junket  becomes  firm,  place  in  ice  until  needed. 

Ice  Creams 

Plain  Vanilla,  Lemon,  or  Almond  Ice  Cream 

5574  calories 

1  cup  thin  cream  |  tsp.  vanilla,  lemon  extract, 

2  tbs.  sugar  (more  if  desired)  or  almond  extract 


FORMULAS  FOR  PREPARATION  OF  FOOD  FOR  SICK    103 

Method  I.     Whip  cream,  add  sugar  and  flavoring,  and  freeze. 

Method  II.  Scald  half  the  cream  and  cool.  Whip  the  remain- 
ing half,  add  sugar  and  flavor  and  freeze. 

Method  III.  Make  "boiled  custard,"  as  directed,  add  one-half 
the  amount  of  cream  and  freeze. 

To  reenforce  ice  cream,  add  1  or  2  egg  whites,  beaten  or  un- 
beaten ;  these  may  be  added  in  the  beginning,  or  after  the  mixture 
begins  to  freeze.  A  tablespoonful  of  maple  sirup,  caramel  sirup 
(1  tbs.  sugar  melted  and  browned  and  dissolved  in  1  tbs.  boiling 
water),  or  chocolate  sirup  may  be  poured  over  the  ice  cream  to 
vary  the  flavor.  Make  chocolate  sirup  by  boiling  2  tbs.  water, 
1  tbs.  sugar,  and  1  tbs.  chocolate  to  a  sirup.     143.3  calories. 

Junket  Ice  Cream 

415-8  calories 

^  cup  each  cream  and  rich  milk  2  tbs.  sugar 

1  junket  tablet  J  tsp.  vanilla 

Heat  cream  and  milk  to  100°  F.  and  proceed  as  in  junket. 
When  mixture  is  jellied  turn  into  freezer,  as  any  ice  cream. 
This  is  the  most  wholesome  of  ice  creams  and  especially  suited 
for  children  and  patients  who  have  tuberculosis  complicated 
with  gastric  disturbances. 

Angel  Food  Cake 

1  small  cake,  755  calories 

4  egg  whites  J  cup  flour  (pastry) 

J  cup  sugar  J  tsp.  cream  of  tartar 

Whip  eggs  until  foamy  and  add  cream  of  tartar,  whip  until 
stiff  and  dry,  add  sugar  gradually,  then  fold  in  the  flour  (the 
flour  must  be  sifted  4  or  5  times). 

Pour  batter  into  an  ungreased  angel  food  cake  pan  and  bake 
in  a  slow  oven  for  25  or  30  minutes.  Care  must  be  taken  not  to 
disturb  the  cake  during  the  baking,  or  it  will  fall. 


104  DIETETICS  FOR  NURSES 

Sunshine  Cake 
836  calories 
7  egg  whites  1  cup  sugar 

5  egg  yolks  f  tsp.  cream  of  tartar 

1  cup  flour  (sifted  3  or  4  times)         J  tsp.  salt 

Beat  whites  of  eggs  until  foamy  and  add  cream  of  tartar ;  beat 
until  dry  and  stiff,  add  the  sugar  gradually  and  fold  in  the  well- 
beaten  yolks.  Sift  the  flour  and  gradually  fold  into  the  rest  of 
the  ingredients ;  pour  into  ungreased  sponge  cake  pans  and  bake 
in  a  moderate  oven  for  30  to  40  minutes. 


SECTION  II 

THE  HUMAN  MACHINE  AND  ITS  RELATION 

TO  FOOD 


CHAPTER  VI 

THE  HUMAN  BODY 

It  has  been  estimated  by  various  writers  that  the  human  body 
has  an  approximate  average  chemical  composition  ^  of  — 

Oxygen about  65  per  cent 

Carbon about  18  per  cent 

Hydrogen about  10  per  cent 

Nitrogen about  3  per  cent 

Calcium about  2  per  cent 

Phosphorus about  1  per  cent 

Potassium about  0.35  per  cent 

Sulphur about  0.25  per  cent 

Sodium about  0.15  per  cent 

Chlorine about  0.15  per  cent 

Magnesium about  0.05  per  cent 

Iron about  0.004  per  cent 

Iodine     1 

Fluorine  > very  minute  quantities 

Silicon    J 

These  chemical  elements  are  combined  to  make  up  the  various 
parts  of  the  body  just  as  they  are  combined  to  make  up  the  dif- 
ferent foodstuffs. 

Proteins.  —  The  carbon,  hydrogen,  oxygen,  nitrogen,  sulphur, 
phosphorus,  and  iron  are  combined  and  constitute  the  proteins  of 
the  body,  as  albumins  and  globulins  of  the  muscular  tissues  and  the 
blood,  as  nucleoproteins  in  the  highly  nucleated  cells  of  the  glan- 
dular organs,  such  as  the  liver,  thymus,  and  pancreas,  etc.,  as 
elastin  and  collagen  of  the  connective  tissues,  tendons,  etc.,  as 
ossein  of  the  bones,  asphosphoprotein  of  the  brain,  as  casein  and 
lactalbumen  in  the  milk  of  all  mammals,  and  as  hemoglobin  in 
the  red  cells  of  the  blood. 

Carbohydrates.  —  Carbon,  oxygen,  and  hydrogen  are  combined 
as  glycogen  and  glucose,  the  former  being  the  form  in  which  the 

1 "  Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 
107 


108  DIETETICS  FOR  NURSES 

carbohydrates  are  stored  in  the  Uver  and  tissues  for  use  as  fuel  in 
the  body,  the  latter  the  form  in  which  the  carbohydrate  circulates 
in  the  blood. 

Fats.  —  Carbon,  hydrogen,  and  oxygen  are  combined  to  form 
the  fats  of  the  human  body  as  they  are  to  form  the  fats  of  food. 
The  human  fats  occur  as  adipose  tissue,  surrounding  the  various 
organs,  protecting  them  from  shocks  and  bruises,  as  phospho-fats 
and  lecithin  of  the  brain,  as  marrow  in  the  bones,  especially  in 
the  long  bones,  and  as  fat  droplets  throughout  the  muscular  tissue 
of  the  body. 

Water.  —  Constituting  more  than  two-thirds  of  the  body  weight, 
is  composed  of  hydrogen  and  oxygen,  and  is  distributed  through- 
out the  body  in  every  tissue  and  fluid,  entering  into  and  forming 
an  essential  part  of  every  active  cell. 

Mineral  Salts  or  Ash.  —  The  eight  remaining  chemical  elements 
constitute  the  mineral  salts  or  ash  constituents;  these  exist  in 
the  body  and  take  part  in  its  functions  in  at  least  three  different 
ways,  according  to  Sherman,^  namely :  (1)  As  the  constituents 
which  give  rigidity  and  comparative  permanence  to  the  skeleton ; 

(2)  as  essential  elements  of  the  protoplasm  of  the  active  tissues ; 

(3)  as  salts  held  in  solution  in  the  fluids  of  the  body,  giving  to  these 
fluids  their  characteristic  influence  upon  the  elasticity  and  irrita- 
bility of  muscles  and  nerves,  supplying  the  material  for  the  acidity 
or  alkalinity  of  the  digestive  juices  and  other  secretions,  and  yet 
maintaining  the  neutrality  or  slight  alkalescence  of  the  internal 
fluids  as  well  as  their  osmotic  pressure  and  solvent  powers. 

The  Utilization  of  Food  by  Body.  —  When  a  comparison  is  made 
of  the  chemical  composition  of  food  with  that  of  the  human  body, 
it  is  seen  that  they  are  practically  the  same.  What  is  more  rea- 
sonable than  that  the  body  should  utilize  food  which  is  of  like  com- 
position, instead  of  drawing  upon  its  own  structure  for  material 
to  carry  on  its  various  functions?  From  an  economical  stand- 
point this  is  the  only  wise  course  to  pursue,  since  a  constant  use  of 
body  material  would  eventually  deplete  the  entire  store.  This 
takes  place  in  cases  of  starvation  and  in  those  diseases  wherein 

8  *'  Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


THE  HUMAN  BODY  109 

the  tissues  of  the  body  are  more  quickly  broken  down  than  they 
can  be  rebuilt. 

The  Body  as  an  Engine.  —  A  comparison  is  made  of  the  human 
body  with  a  steam  engine.  This  comparison  is  inadequate,  since 
the  man-made  machine  is  in  constant  need  of  a  directing  intelli- 
gence ;  alone  it  cannot  turn  a  wheel,  neither  can  it  repair  even  the 
smallest  break,  or  the  tiniest  screw  which  may  become  out  of 
order.  On  the  other  hand  the  wheels  of  the  human  machine  are 
ever  moving ;  day  and  night,  sleeping  or  waking,  at  work  or  at 
rest,  the  work  goes  on,  ceasing  only  with  life  itself.  As  one  part 
becomes  worn  out,  it  is  discarded,  and  the  part  rebuilt  with  new 
material.  To  quote  Lusk :  "  The  workshops  of  life  are  in  a  con- 
stant state  of  partial  breaking  down  and  materials  must  be  fur- 
nished to  repair  the  worn-out  parts.  In  the  fuel  factor  and  the 
repair  factor  lie  the  essence  of  the  science  of  nutrition."  ' 

Utilization  of  Food  by  the  Body.  —  The  utilization  of  the  food- 
stuffs in  the  body  forms  the  basis  of  our  study  of  dietetics.  It  has 
been  proved  that  there  is  a  continual  breaking-down  and  building- 
up  process  taking  place  in  the  living  cells.  The  expenditure  of 
energy  involved  and  liberated  as  a  result  of  these  internal  activi- 
ties leaves  the  body  chiefly  in  the  form  of  heat,  while  the  end 
products  of  the  material  thus  utilized  are  cast  out,  leaving  by  way 
of  the  excretory  organs,  the  lungs,  the  skin,  the  kidneys,  and  the 
intestines. 

Metabolism  of  Body  Tissues.  —  The  constant  breaking  down 
and  building  up  of  the  tissues  of  the  body  and  the  evolution  of  heat 
as  a  by-product  of  the  energy  expended  may  be  summed  up  in 
the  term  "  metabolism."  The  metabolism  of  the  body  is  normally 
supported  by  the  food  ingested.  However,  it  is  a  known  fact 
that  were  no  food  eaten  the  processes  would  continue  just  the  same, 
the  difference  only  being  the  use  of  the  body  structure  instead  of 
food  materials.  According  to  Sherman,*  the  chemical  changes  and 
energy  transformations  are  of  course  inseparable.  It  has  become 
customary  to  speak  of  the  metabolism  of  matter  and  the  metabo- 

8"  The  Fundamental  Basis  of  Nutrition,"  by  Graham  Lusk. 
^  "  Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


no  DIETETICS  FOR  NURSES 

lism  of  energy,  and  to  regard  the  extent  of  the  metabolism 
of  any  material  substance  as  measured  by  the  amount  of  its 
end  products  eliminated,  and  the  extent  of  the  energy  metabolism 
as  measured  by  the  amount  of  heat  or  of  heat  and  external  muscular 
work  which  the  body  gives  off. 

Selection  of  Food  by  Body.  —  To  understand  the  changes 
through  which  it  is  necessary  for  the  foods  to  pass  before  they 
become  available  for  use  in  the  body,  it  is  necessary  to  understand 
which  foods  are  utilized  most  economically  by  the  body  for  the 
various  processes,  namely,  those  which  can  be  used  to  carry  on 
the  internal  and  external  work  and  those  used  by  the  body  to  re- 
pair the  worn-out  parts  and  to  furnish  material  for  growth.  A 
glance  at  Table  I  shows  the  chemical  combinations  used  for  these 
purposes. 

Food  as  Fuel.  —  We  are  fully  justified,  according  to  Armsby, 
"  in  speaking  of  the  food  as  body  fuel,  and  in  our  studies  of  its 
utilization  we  may  be  confident  that  any  food  energy  which  does 
not  appear  in  the  form  of  heat  or  work  has  not  been  lost,  but  has 
been  stored  up  in  the  body  as  the  chemical  energy  of  meat,  fat,  etc., 
which  may  later  serve  to  supply  food  energy  to  the  human  body." 

Processes  of  Metabolism.  —  Under  metabolism  we  may  in- 
clude several  processes,  namely,  digestion,  absorption,  and  as- 
similation. Digestion  includes  all  of  the  changes  through  which 
the  food  in  its  original  form  must  pass  before  it  can  be  rebuilt 
under  the  influence  of  the  living  cells  into  actual  body  material. 
Absorption  is  really  a  part  of  digestion  since  it  involves  the  pas- 
sage of  the  reconstructed  compounds  through  the  absorbing  walls 
of  the  intestinal  or  digestive  tract.  Assimilation  includes  the 
work  of  the  active  cells.  The  materials  originally  ingested,  having 
passed  through  the  various  digestive  processes,  are  selected  by 
these  cells  and  reconstructed  into  other  substances  according  to 
the  various  needs  of  the  body. 

Mechanical  and  Chemical  Digestion.  —  Taking  these  processes 
in  order  of  progression,  we  begin  with  the  digestion.  The  prepara- 
tion of  the  food  materials  within  the  body  is  the  result  of  both 
mechanical  and  chemical  agents  which  act  simultaneously  through- 


THE  HUMAN  BODY  111 

out  the  entire  digestional  tract.  In  the  mouth,  the  muscles  of  the 
tongue  and  jaw  together  with  the  teeth  masticate  and  mix  the 
food  with  the  fluid  from  the  salivary  glands  which  open  into  the 
mouth.  Mastication  is  an  entirely  voluntary  movement  which 
tends  to  liquefy  the  food  to  a  certain  extent  and  facilitate  its  pas- 
sage into  the  stomach.  After  the  food  is  swallowed  the  move- 
ments which  occur  in  the  rest  of  the  alimentary  tract  are  involun- 
tary in  character  and  cannot  be  controlled  at  will. 

Arrangement  of  Food  in  the  Stomach.  —  To  simplify  the  study 
of  the  gastric  organs  it  may  be  well  to  think  of  the  stomach  as  being 
divided  into  three  regions,  i.e.,  "  the  fundus,  the  middle  region,  and 
the  pyloric  end,"  ^  each  of  which  differs  slightly  from  the  other. 
After  being  swallowed,  the  food  enters  the  region  situated  at  the 
cardiac  end,  known  as  the  fundus.  This  food  mass  arranges  itself 
in  layers ;  according  to  Howell  ^  "  such  an  arrangement  is  more 
readily  understood  when  one  recalls  that  the  stomach  has  never 
any  empty  space  within  —  its  cavity  is  only  as  large  as  its  con- 
tents, so  that  the  first  portion  of  food  eaten  entirely  fills  it  and 
successive  portions  find  the  wall  layer  occupied  and  are  therefore 
received  into  the  interior.  The  ingestion  of  much  liquid  must 
interfere  somewhat  with  this  stratification." 

Stomach  Movements.  —  The  fundus  has  practically  no  move- 
ments, save  the  contraction  of  the  walls.  As  the  walls  of  the 
fundus  become  distended  by  the  intake  of  food,  they  gently  con- 
tract upon  the  mass,  forcing  the  portion  which  entered  first  into 
the  "  second  "  or  "  middle  region."  In  this  region  the  peristaltic 
waves  begin  and  travel  toward  the  pylorus  and  increase  in  force 
as  digestion  progresses,  ceasing  only  with  the  emptying  of  the 
organ.  When  the  first  stratum  of  food  reaches  the  middle  of  the 
stomach  it  is  caught  by  these  oscillating  peristaltic  waves  and 
forced  forward  through  the  pyloric  region  and  against  the  pylorus, 
from  whence  it  is  returned  back  through  rings  of  constriction. 
This  forward  and  backward  movement  continues  as  long  as  there 
is  food  in  the  stomach. 

'  "  Chemistry  of  Food  and  Nutrition,"  by  Sherman. 
•  "  Textbook  of  Physiology,"  by  Howell. 


112  DIETETICS  FOR  NURSES 

Distribution  of  Secretory  Cells.  —  Secretory  cells  are  distributed 
in  each  of  the  three  regions  of  the  stomach,  but  are  more  numerous 
in  the  middle  region  than  at  either  end.  The  third  region  includes 
the  pyloric  vestibule  through  which  all  foods  must  pass  before 
they  can  enter  the  small  intestine,  and  terminates  in  the  pylorus, 
the  valve  which  shuts  off  the  stomach  from  the  duodenum  and  the 
rest  of  the  intestinal  canal. 

Passage  of  Food  from  Stomach.  —  The  material  prepared  in 
the  stomach,  known  as  chyme,  is  passed  into  the  duodenum  through 
the  pylorus.  The  opening  of  this  sphincter  is  controlled,  accord- 
ing to  Cannon,  to  a  certain  extent  by  the  liquefication  of  the  chyme, 
but  more  especially  by  the  presence  of  free  acid  in  the  stomach  side 
of  the  pyloric  orifice. 

Behavior  of  Food  in  the  Intestines.  —  The  food  does  not  pass  at 
once  along  the  canal,  but  waits  in  the  duodenum  until  several 
portions  have  passed  through.  As  the  food  mass  is  made  alka- 
line in  the  presence  of  the  intestinal  juices,  the  pyloric  valve  closes, 
opening  again  as  the  contents  nearest  it  on  the  stomach  side  are 
acidified. 

Intestinal  Movements.  —  The  peristaltic  waves  in  the  small 
intestines  begin  in  the  upper  part  and  start  a  course  ever  down- 
ward. These  waves  in  the  intestines  are  two-fold  in  character; 
the  quick  shallow  wave  which  forces  the  food  string  forward, 
breaking  it  up  into  segments,  and  backward  joining  the  segments 
together  again,  and  the  strong  deep  wave  which  carries  the  entire 
mass  forward  after  each  segmentation.  This  method  of  move- 
ment in  the  small  intestines  is  the  best  one  possible  under  the 
conditions  which  prevail  in  this  region  of  the  digestional  apparatus, 
since  it  not  only  mixes  the  food  material  with  the  juices  necessary 
for  its  digestion,  but  likewise  spreads  it  out  over  a  wide  space, 
insuring  a  greater  contact  with  the  absorbing  walls  of  the  small 
intestines. 

Secretory  Cells  in  the  Small  Intestines.  —  Situated  in  the  walls 
in  this  region  are  innumerable  secretory  cells  which  pour  out  their 
secretions  upon  the  food  mass  as  it  is  tossed  back  and  forth  by  peri- 
staltic activity.     Other  cells  situated  in  the  pancreatic  gland  and 


THE  HUMAN  BODY  113 

liver  likewise  furnish  fluids  to  assist  in  the  digestion  of  the  foods  in 
the  intestinal  canal. 

Movements  in  the  Large  Intestine.  —  The  movements  in  the 
large  intestine  or  colon  are  much  like  those  in  other  parts  of  the 
digestive  tract.  The  small  and  large  intestine  are  divided  by  a 
valve  known  as  the  sigmoid  flexure,  and  any  food  which  passes 
through  it  cannot  return,  since  the  valve  is  a  competent  one.. 
The  cells  in  the  walls  of  the  larger  intestine  secrete  fluids  of  a  lubri- 
cating character,  containing  no  enzymes  of  digestion  but  aid  in 
moving  the  fecal  matter  toward  the  rectum. 

Chemical  Digestion.  —  The  chemical  changes  in  the  food  mate- 
rials, after  they  are  eaten,  are  brought  about  through  the  action 
of  certain  substances  known  as  soluble  ferments  or  "  enzymes." 
These  enzymes  exist  in  every  tissue  of  the  body,  and  their  province 
is  first  to  break  down  the  food  materials  themselves  into  simpler 
compounds,  and  then  to  reconstruct  the  simpler  substances  into 
those  of  a  more  complex  character,  which  are  more  available  for 
the  various  uses  of  the  organism. 

Action  of  the  Enzymes.  —  As  Sherman  has  stated,  "  all  fermen- 
tation is  brought  about  either  directly  or  indirectly  by  the  activity 
of  animal  or  vegetable  organisms  or  cells.  When  the  organisms  or 
cells  act  directly  and  the  chemical  changes  occur  only  in  its  presence, 
the  fermentation  is  said  to  be  due  to  an  organized  ferment.  When 
the  action  is  not  brought  about  directly  by  the  cell  itself,  but  by 
means  of  a  substance  secreted  by  the  cell  but  acting  apart  from  it, 
this  substance  is  called  a  soluble  or  unorganized  ferment  or  '  en- 
zyme.' '*  The  enzymes  concerned  in  digestion  and  metabolism, 
their  source  and  their  action,  may  be  found  in  the  following 
table : 


V 


114 


DIETETICS  FOR  NURSES 


TABLE  XIII 7 


Act  upon  car- 
bohydrates 


Acts  on  fats 


Act  on  pro- 
teins 


Act  on  purins 


Enzymes 


Ptyalin  (salivary 
amylase) 

Amylopsin  (pan- 
creatic amylase) 

Liver  diastase 

Muscle  diastase 

Invertase  (su- 
crase) 

Maltase 

Lactase 


Glycolytic      en- 
zymes 
Lipase  (steapsin) 


Pepsin 


Trypsin 


Erepsin 

Autolytic 
zymes 

Guanase 

Adenase 

Oxidases 


Where  Chiefly 
Found 


Salivary      secre- 
tions 
Pancreatic  juice 

Liver 

Muscles 

Intestinal  juice 

Intestinal  juice 
Intestinal  juice 

Muscles,  etc. 

Gastric,  and  pan- 
creatic secre- 
tions, blood 
and  tissues 

Gastric  juice 

Pancreatic  juice 


Intestinal  juice 


Tissue  generally 


Thymus,  adre- 
nals, pancreas 

Spleen,  pancreas, 
liver 

Lungs,  liver, 
muscles,  etc. 


Action 


Converts  starch 
to  maltose 

Converts  starch 
to  maltose 

Converts  glyco- 
gen to  glucose 

Converts  glyco- 
gen to  glucose 

Converts  glycogen 
to  glucose  and 
fructose 

Converts  maltose 
to  glucose 

Converts  lactose 
to  glucose  and 
galactose 

Split  and  oxidize 
glucose 

Splits  fats  to  fatty 
acids  and  gly- 
cerin 

Splits  proteins  to 
proteoses  and 
peptones 

Splits  proteins  to 
proteoses,  pep- 
tones, polypep- 
toids  and  amino 
acids 

Splits  peptones 
to  amino  acids, 
and  ammonia 

Split  body  pro- 
teins to  simpler 
substances 

Changes  guanin 
to  xanthin 

Changes  adenin 
to  hypoxanthin 

Cause  oxidation 
of  hypoxanthin 
to  xanthin  and 
xanthin  to  uric 
acid 


'Compiled  from    "Textbook  of  Physiology,"   by  Howell, 
Food  and  Nutrition,"  by  Sherman. 


and    "Chemistry   of 


THE  HUMAN  BODY  115 

Classification  of  Enzymes.  —  Sherman  classifies  the  enzymes  of 
the  body  according  to  their  effects : 

1.  The  hydrolytic  enzymes: 

(a)  Proteolytic  or  protein-splitting  enzymes. 
(6)  Lipolytic  or  fat-splitting  enzymes. 

(c)  Amylolytic  or  starch-splitting  enzymes. 

(d)  Sugar-splitting  enzymes. 

2.  The  coagulating  enzymes,  such  as  thrombin  or  thrombase 
(the  fibrin  ferment)  and  rennin,  which  causes  the  clotting  of  milk. 

3.  The  oxidizing  enzymes  or  oxidases  (which,  if  the  oxidation 
be  accompanied  by  a  splitting  off  of  amino  groups,  may  be  called 
"  deaminizing  "  enzymes). 

4.  The  reducing  enzymes  or  "  reductases." 

5.  Those  which  produce  carbon  dioxide  without  the  use  of  free 
"  deamidizing  "  oxygen,  such  as  zymase  of  yeast. 

6.  Enzymes  causing  the  breaking  down  of  a  larger  into  a  smaller 
molecule  of  the  same  composition,  as  in  the  production  of  lactic 
acid  from  glucose. 

Digestion  (Chemical) 

Salivary  Digestion.  —  The  table  shows  that  enzymic  action 
begins  in  the  mouth.  Saliva,  the  characteristic  secretion  of  this 
region,  contains  the  enzyme  ptyalin  which  exerts  its  influence 
upon  the  starches  and  dextrins.  The  food  mass  remains  in  the 
mouth  for  so  short  a  time,  however,  that  a  very  small  percentage 
of  the  starch  is  changed  to  maltose  under  salivary  digestion.  The 
action  of  ptyalin,  however,  continues  in  the  fundus  of  the  stomach 
until  stopped  by  the  acid  in  the  gastric  juice. 

Gastric  Digestion.  —  The  conditions  existing  in  this  region  of 
the  gastric  organ  of  digestion  are  particularly  favorable  to  the 
continuance  of  salivary  digestion  on  account  of  the  neutral  char- 
acter of  the  juices  secreted  by  the  cells  there,  and  because  there  is 
so  little  movement  taking  place.  The  cells  in  the  middle  region, 
however,  secrete  a  fluid  rich  in  acid,  and  as  the  food  mass  is  grad- 
ually pushed  forward  by  the  contraction  of  the  stomach  walls  into 


116  DIETETICS  FOR  NURSES 

this  portion  of  the  stomach,  further  conversion  of  starch  and 
dextrin  to  maltose  is  checked.  Gastric  juice  is  secreted  by  cells 
situated  in  all  parts  of  the  stomach.  The  character  of  the  secre- 
tions differs  in  different  parts  of  the  organ.  However,  that  in 
the  fundus  is  neutral  in  character  or  even  slightly  alkaline,  accord- 
ing to  Howell,  while  that  in  the  middle  region  is  highly  acid.  The 
pyloric  end  of  the  stomach  exhibits  strong  peptonizing  powers  and 
much  of  the  hydrolysis  of  protein  takes  place  here.  As  the  food 
is  pushed  out  of  the  fundus  it  is  caught  by  the  waves  of  peristaltic 
action  and  swept  toward  the  pylorus.  This  movement  of  the 
food  mass  to  and  from  the  pylorus  under  the  influence  of  the  mus- 
cular constriction  in  the  stomach  tends  to  mix  it  thoroughly  with 
the  juices  in  all  parts  of  the  stomach,  and  in  a  measure  to  liquefy 
it  to  the  "  souplike  "  mixture  known  as  chyme. 

Composition  of  the  Gastric  Juice.  —  The  active  characteristics 
of  the  gastric  juice  are  centered  in  the  secretion  of  hydrochloric 
acid  and  the  proteolytic  enzyme  "  pepsin."  The  latter  acts  only 
in  an  acid  medium,  consequently  the  food  must  first  come  in  con- 
tact and  be  saturated  with  the  hydrochloric  acid  before  the  pro- 
teins can  be  acted  upon  and  hydrolyzed  to  proteosis  by  the  enzymes 
in  the  pyloric  end  of  the  stomach.  The  second  proteolytic  enzyme 
in  the  gastric  juice  is  rennin.  This  has  the  property  of  clotting 
sweet  milk.  The  third  enzyme  of  the  gastric  secretion  is  a  fat- 
splitting  lipase  which  acts,  however,  only  upon  the  finely  divided 
fats  or  emulsions  such  as  cream,  milk,  and  egg  yolk. 

The  opening  of  the  pyloric  valve  does  not  occur  with  every  wave 
of  peristalsis.  Science  has  proved  that  the  relaxation  of  this  valve 
occurs  only  in  the  presence  of  free  hydrochloric  acid.  A  small 
portion  is  injected  into  the  duodenum  at  each  opening  and  remains 
there  until  neutralized  by  the  alkaHne  salts  in  the  intestinal 
juices. 

The  Efifect  of  Muscular  Constrictions.  —  The  muscular  con- 
strictions occurring  in  the  intestines  producing  segmentation  of 
the  food  string  have,  according  to  Sherman,  the  effect  of  "  (1) 
further  mixing  of  the  food  and  digestive  juices,  (2)  bringing  the  di- 
gested food  into  contact  with  the  absorbing  membrane,  (3)  empty- 


THE  HUMAN  BODY  117 

ing  the  venous  and  l^Tnphatic  radicles  in  the  membrane,  the  mate- 
rial which  they  have  absorbed  being  forced  into  the  veins  and  lymph 
vessels  by  the  compression  of  the  intestinal  walls."  ^ 

Stimulation  of  Intestinal  Secretions.  —  The  flow  of  the  intes- 
tinal juices  is  stimulated  by  a  substance  or  hormone  known  as 
"  secretin."  This  hormone  is  the  result  of  the  action  of  hydro- 
chloric acid  upon  some  substance  in  the  intestinal  wall.  Starling  ^ 
claims  that  the  formation  of  hormones  and  their  circulation  through 
the  blood  to  the  reactive  tissues  is  sufiicient  to  account  for  the 
activity  of  the  pancreas ;  he  doubts  if  the  nervous  system  plays 
any  part  in  the  activity  of  that  organ. 

IntestiAal  Digestion.  —  Digestion  proceeds  in  an  orderly  manner 
throughout  the  intestinal  canal.  The  pancreatic  juice,  bile,  and 
intestinal  juice  are  poured  upon  the  food  mass  on  its  entrance  into 
the  duodenum.  The  enzymes  work  simultaneously.  Trypsin 
in  the  pancreatic  juice  takes  up  the  hydrolysis  of  the  proteoses 
and  peptones  and  those  proteins  which  have  escaped  gastric  diges- 
tion. The  amylopsin  likewise  in  the  pancreatic  secretion  acts 
upon  the  starch  and  dextrin,  changing  them  to  maltose.  The 
lipases  split  the  fats  to  fatty  acids  and  glycerol. 

The  erepsin  in  the  intestinal  juice,  "  succus  entericus,''  brings 
about  further  change  in  the  proteins,  with  the  production  of  amino 
acids.  The  bulk  of  the  carbohydrates  are  converted  into  monosac- 
charides in  the  smaller  intestines.  The  lactose,  maltose,  and 
sucrose  are  changed  through  the  activity  of  the  lactase,  malt- 
ase,  and  invertase  into  glucose.  Sherman  states  that  "  it  is 
possible  that  the  splitting  of  the  lactose  (milk  sugar)  may  occur  in 
the  intestinal  wall  rather  than  in  the  food  mass."  ^° 

Bile.  —  Human  bile,  the  secretion  most  actively  concerned  in 
the  digestion  and  absorption  of  the  fats,  contains  water,  bile  salts, 
bile  acids,  bile  pigments,  cholesterin,  lecithin,  and  a  peculiar 
protein  derived  from  the  mucous  membranes  of  the  bile  ducts  and 
gall  bladder. 

8  "Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 

9  "Recent  Advances  in  the  Physiology  of  Digestion,"  by  Starling. 
10  "Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


118  DIETETICS  FOR  NURSES 

Action  of  Bile  upon  Fat.  —  The  fats,  as  has  already  been  stated, 
have  been  split  through  the  activity  of  the  lipases  into  fatty  acids 
and  glycerol.  The  glycerol  is  readily  soluble  in  water,  while 
the  bile  quickly  dissolves  the  fatty  acids.  Bile  likewise  diminishes 
the  surface  tension  between  oily  and  watery  fluids  and  for  this 
reason  augments  the  digestion  of  the  proteins  and  carbohydrates 
as  well  as  the  fats.  The  bile  acids  are  absorbed  to  a  large  extent 
and  re-secreted  by  the  liver.  According  to  Starling  "  bile  must 
also  be  considered  as  an  excretion,  representing  as  it  does  the  chan- 
nel by  which  the  products  of  disintegration  of  hemoglobin,  red 
coloring  matter  of  the  blood,  are  gotten  rid  of  by  the  organism." 
Investigation  has  proved  that  while  the  secretion  of  bile  by  the 
liver  is  continuous,  its  injection  into  the  intestines  occurs  only 
during  the  process  of  digestion. 

Digestion  in  the  Larger  Intestine.  —  Science  has  proved  that 
most  of  the  nourishing  part  of  the  food  ingested  is  digested  and 
absorbed  before  it  reaches  the  larger  intestine.  The  two  portions 
of  the  alimentary  canal  known  as  the  small  and  large  intestine  are 
separated  by  the  ileocecal  valve.  Cannon  claims  "  that  this 
valve  is  competent,  that  is,  under  noi-mal  conditions  the  food  mass 
which  passes  through  into  the  colon  cannot  be  forced  back  into 
the  small  intestine."  The  food  mass  sometimes  contains  materials 
which  have  escaped  digestion,  likewise  some  of  the  active  enzymes 
which  bring  about  their  hydrolysis,  in  which  case  a  certain  amount 
of  their  digestion  may  continue  in  the  large  intestine. 

So  far,  investigators  have  found  no  enzymes  in  the  fluids  secreted 
by  the  cells  in  the  walls  of  the  large  intestine,  but  they  have  found 
an  alkaline  fluid  which  assists  in  completing  the  digestion  of  the 
foods  which  has  started  in  other  parts  of  the  intestinal  tract. 

Absorption.  —  Absorption  of  food  occurs  in  all  parts  of  the  in- 
'testinal  canal,  but  the  major  portion  of  it  occurs  in  the  small  in- 
testines, the  mucous  membrane  lining  of  which  seems  particularly 
adapted  for  this  purpose.  According  to  Taylor  there  is  no  absorp- 
tion of  fats,  carbohydrates,  or  proteins  in  the  stomach.  Other  in- 
vestigators believe  that  some  of  the  protein  is  absorbed  and  also 
some  glucose  in  concentrated  solution.     However,  the  stomach 


THE  HUMAN  BODY  119 

cannot  be  considered  of  great  value  as  an  absorbing  organ.  Physi- 
ology teaches  that  the  absorption  of  the  products  of  digestion 
occurs  by  means  of  the  millions  of  small  projections  or  villi  with 
which  the  intestinal  wall  is  lined.  These  villi  contain  numerous 
capillary  blood  vessels  and  spaces  known  as  lacteals.  The  former 
converge  into  the  portal  vein,  the  latter  into  the  lymphatic  vessels 
and  thence  into  the  thoracic  ducts. 

The  Absorption  of  Fat.  —  The  fats,  as  has  been  described,  are 
split  into  their  two  constituents,  fatty  acid  and  glycerol.  The 
former  is  dissolved  by  the  bile  to  form  soap ;  the  latter  is  readily 
soluble  in  water.  These  constituents  thus  dissolved  pass  through 
the  walls  and  recombine  in  the  form  of  neutral  fat  droplets,  prob- 
ably during  the  passage  through  the  walls,  since  they  appear  in 
this  form  in  the  cells.  They  pass  into  the  thoracic  duct  and  thence 
into  the  blood  stream. 

Absorption  of  Carbohydrates.  —  The  carbohydrates  are  chiefly 
absorbed  in  the  form  of  monosaccharides.  This  has  been  proved 
by  introducing  cane  sugar  or  lactose  into  the  blood  vessels  and 
getting  the  greater  portion  of  it  back  unchanged  by  way  of  the 
urine.  As  the  monosaccharides  are  taken  up  by  the  capillaries 
lining  the  walls  of  the  small  intestines,  they  are  passed  on  to  the 
portal  vein  and  carried  by  the  portal  blood  into  the  liver,  where 
they  are  stored  temporarily  as  glycogen,  and  given  out  to  the 
blood  in  the  form  of  glucose  as  needed.  After  a  meal  rich  in  carbo- 
hydrates, the  portal  blood  will  be  rich  in  glucose,  while  the  blood 
in  general  circulation  contains  about  the  same  amount  as  usual, 
about  0.1  per  cent. 

Absorption  of  Proteins.  —  The  absorption  of  the  products  of 
protein  digestion  occurs  through  the  capillary  blood  vessels  and 
passes  on  to  the  portal  vein.  The  metabolism  of  protein  is  more 
complex  than  of  that  of  any  of  the  foodstuffs.  It  is  probable  that 
each  living  cell  contains  enzymes  which  are  capable  of  breaking 
down  the  body  proteins  with  the  production  of  amino  acids  just 
as  the  proteins  of  the  food  are  broken  down  by  enzymes  of  diges- 
tion, and  according  to  Sherman  "  it  is  not  improbable  that  protein 
synthesis  also  may  be  brought  about  by  every  living  cell." 


120  DIETETICS  FOR  NURSES 

The  Absorption  of  Water.  —  Does  not  occur  in  the  stomach,  as 
was  formerly  believed,  but  in  the  small  intestines. 

The  Absorption  of  the  Mineral  Salts.  —  Occurs  in  conjunction 
with  the  other  food  material.  Some  of  the  mineral  salts  are  much 
more  soluble  than  others  and  are  more  readily  absorbed.  The 
function  of  the  mineral  salts  in  the  body  has  already  been  de- 
scribed, and  since  they  form  a  part  of  every  tissue  and  fluid  in  the 
body  their  absorption  and  fate  in  metabolism  must  be  studied 
with  that  of  the  other  chemical  combinations. 


ABSORPTION   IN   THE   LARGE   INTESTINES 

The  digestion  of  the  food  as  it  is  passed  into  the  last  portion  of 
the  alimentary  canal  has  been  largely  completed.  However,  that 
part  which  has  escaped  digestion  in  the  small  intestine  is  finished 
and  absorbed  here.  The  important  peristaltic  waves  occurring 
in  this  region  are  antiperistaltic  in  character  and  have  the  property 
of  churning  the  food  thoroughly  and  bringing  a  larger  portion  of 
it  in  contact  with  the  absorbing  walls.  The  water  which  is  left 
in  the  food  mass  together  with  the  products  of  the  digestion  of  the 
foodstuffs  is  absorbed  in  the  first  part  of  the  large  intestine,  leaving 
the  remainder  more  solid.  This  residue  is  known  as  feces  or  fecal 
matter. 

Factors  Influencing  Digestion.  —  There  are  various  factors 
which  play  a  part  or  have  an  influence  upon  the  digestion  of  food 
in  the  body.  Those  involved  in  good  salivary  digestion  are 
mechanical,  chemical,  and  psychical,  the  teeth  and  tongue  grinding 
and  mixing  the  food  with  the  saliva.  The  foods  requiring  chewing 
stimulate  a  flow  of  salivary  acids,  and  excite  a  flow  of  saliva,  but 
tend  to  check  the  action  of  the  salivary  amylase,  ptyalin.  The 
sight,  smell,  and  taste  all  act  together,  stimulating  the  flow  of 
saliva,  thus  increasing  digestion  in  the  mouth. 

Factors  Influencing  Gastric  Digestion.  —  The  factors  influencing 
digestion  in  the  stomach  constitute  all  those  mechanical,  electrical, 
chemical,  and  psychical  factors  which  stimulate  or  retard  the  action 
of  the  gastric  juices.     The  movements  in  the  stomach  are  in  vol- 


THE  HUMAN  BODY  121 

untary,  but  their  activities  may  be  stimulated  by  the  flow  of  gas- 
tric juice.  Sleep  retards  digestion  in  the  stomach  by  retarding 
the  movements  in  the  organ  itself. 

Stimuli  to  Gastric  Flow.  —  The  division  and  liquefaction  of  the 
food  in  the  mouth  hastens  gastric  digestion  by  making  the  food 
better  fitted  for  the  action  of  the  enzymes  in  the  gastric  juice. 
The  type  as  well  as  the  character  of  the  food  acts  as  a  stimulus  to 
the  gastric  secretion. 

Water  is  probably  the  best  of  all  the  agents  for  stimulating  the 
secretion  of  gastric  juice,  while  dextrin  (toast,  zwiebach)  and  the 
extractives  of  meat  likewise  exert  similar  powers. 

Retarding  the  Gastric  Flow.  —  The  nervous  system,  on  the 
other  hand,  at  times  checks  or  entirely  inhibits  a  flow  of  these 
juices.  Worry,  excitement,  anger,  fatigue,  chill,  each  plays  its 
part  in  promoting  poor  digestion  in  the  gastric  organ.  As  chem- 
ical factors,  water  and  salts  are  the  two  necessary  substances  for 
gastric  digestion,  since  the  enzymes  in  the  juices  cannot  act  except 
in  their  presence. 

Alkaline  carbonates  and  fatty  foods  both  check  the  flow  of 
gastric  juice,  and  retard  digestion.  The  psychic  factors  which 
result  in  a  stimulation  of  the  secretory  cells  in  the  stomach  are 
exerted  through  the  sight,  smell,  and  taste.  One  often  hears  the 
expression  :  "  The  food  looked,  smelled,  or  tasted  so  good  that  it 
made  my  mouth  water."  This  actually  occurs ;  hence  the  secre- 
tion has  been  named  appetite  juice.  This  appetite  juice  acts  as 
a  direct  stimulant  to  the  cells  in  the  mucous  lining  of  the  stomach, 
causing  a  flow  of  gastric  juice.  It  cannot  be  said  to  cause  diges- 
tion, but  it  certainly  institutes  that  process,  thus  starting  the 
whole  digestional  procedure. 

Factors  Influencing  Rate  of  Food  Passage.  —  As  has  already 
been  stated,  the  passage  of  food  from  the  stomach  is  dependent 
upon  the  free  acids,  organic  or  hydrochloric,  in  the  stomach,  and 
the  type  of  food  determines  in  a  measure  the  rate  with  which  the 
organ  is  emptied.  Numerous  investigators  have  proved-  that 
certain  foods  leave  the  stomach  before  others.  This  is  chiefly  de- 
pendent upon  the  amount  of  acid  required  by  them  for  saturation. 


122  DIETETICS  FOR  NURSES 

Rate  of  Carbohydrates,  Proteins,  and  Fats.  —  Carbohydrates, 
for  example,  do  not  require  any  acid  for  their  digestion,  hence  all 
of  the  acid  with  which  they  come  in  contact  can  go  toward  acidi- 
fying them,  while  the  proteins  require  hydrochloric  acid  before 
the  enzymes  can  begin  to  exert  their  activities.  Consequently 
they  leave  the  stomach  much  more  slowly  than  the  carbohydrates. 
The  fats  leave  more  slowly  than  any  of  the  other  food  combina- 
tions. If  carbohydrates  and  proteins  are  taken  together  they 
leave  the  stomach  more  slowly  than  if  the  carbohydrates  were 
fed  alone,  but  more  quickly  than  they  would  if  the  meal  consisted 
of  protein  alone.  When  the  meal  consists  of  fats  and  proteins, 
the  stomach  is  emptied  more  slowly  than  is  the  case  when  either 
is  fed  alone. 

Taylor  and  other  investigators  hold  that  '^  the  function  of  the 
pancreas  and  of  the  secretory  activity  of  the  small  intestine  are 
dependent  upon  the  secretions  and  motor  processes  of  the  stomach." 
However,  it  is  an  established  fact  that  at  least  three-quarters  of 
the  work  of  digestion  is  accomplished  in  this  part  of  the  alimentary 
canal,  and  in  certain  pathological  conditions  in  which  the  gastric 
organ  is  so  badly  diseased  as  to  require  partial  removal,  the  entire 
work  of  the  digestion  of  the  food  may  be  carried  on  and  completed 
in  the  small  intestine. 

There  is  no  doubt  as  to  the  desirability  of  good  salivary  and 
gastric  digestion,  since  it  would  be  unwise  to  force  one  part  of  the 
organism  to  work  at  the  expense  of  another.  Physiologists  have 
proved  that  the  activity  of  the  pancreas  and  other  secretory  organs 
are  stimulated  by  hydrochloric  acid  secreted  by  the  cells  situated 
in  the  mucous  lining  of  the  stomach  walls.  Hence  any  stimula- 
tion of  these  cells  by  water,  extractives,  etc.,  results  in  an  increased 
flow  of  hydrochloric  acid,  and  a  consequent  stimulation  of  the 
above-mentioned  secretory  organs.  Thus,  one  organ  assists  the 
other,  and  the  whole  process  proceeds  to  a  harmonious  completion. 

Bacterial  Action  in  the  Alimentary  Canal.  —  The  changes  in 
the  foods  so  far  mentioned  have  been  chiefly  the  result  of  the  ac- 
tivity of  the  enzymes  existing  in  the  various  digestive  processes 
throughout  the  body.     But  there  are  other  changes  which  occur 


THE  HUMAN  BODY  123 

in  the  foods  during  their  sojourn  in  the  digestive  tract  which  are 
not  accountable  to  enzymic  action,  but  which,  in  fact,  modify  to  a 
certain  degree  the  changes  wrought  by  the  enzymes.  These  are 
the  result  of  the  activity  of  certain  specific  bacteria  which  inhabit 
the  entire  digestive  tract  of  the  individual  from  a  few  hours  after 
birth  until  death.  Some  of  these  have  so  adapted  themselves  to 
the  existing  conditions  that,  unless  present  in  overwhelming  num- 
bers, they  are  not  only  harmless,  but  they  actually  assist  in  pro- 
tecting the  organism  from  the  inroads  of  more  harmful  species. 
Many  experiments  have  been  made  to  find  whether  or  not  bacteria 
are  essential  to  human  nutrition,  and  the  results  of  these  experi- 
ments prove  that  they  are  not.  However,  since  they  are  so  firmly 
established  in  the  body  it  is  well  to  study  the  various  types  and 
learn  as  much  as  possible  of  the  products  of  their  activity  and  the 
influence  which  they  exert  in  human  nutrition. 

Type  of  Bacteria.  —  It  would  be  impossible  and  unnecessary 
to  consider  the  action  of  all  of  the  bacteria  in  the  body  in  this  text, 
but  it  is  necessary  to  consider  those  which  are  prominent  in  bring- 
ing about  decomposition  of  the  foods  in  the  digestive  tracts  Sher- 
man holds  that  there  are  three  main  types  having  this  property : 
"(1)  the  bacteria  of  fermentation,  such,  for  example,  as  the  lactic 
acid  bacteria ;  (2)  the  putrefactive  bacteria,  such  as  the  anaerobic 
B.  aerogenes  capsulatus ;  (3)  bacteria  of  the  B.  coli  type,  showing 
the  character  of  both  the  fermentative  and  putrefactive  organisms, 
but  tending  in  general  to  antagonize  the  putrefactive  anaerobes.  "^^ 

Fermentation  in  the  Stomach.  —  In  the  stomach,  fermentation 
of  the  carbohydrates  with  the  production  of  organic  acids,  and  at 
times  alcohol,  occurs.  The  types  of  fermentation  taking  place  in 
the  stomach  are  alcoholic,  lactic,  butyric,  acetic,  formic,  oxalic,  and 
cellulose.  The  bacteria  inhabiting  the  gastric  organs  are  depend- 
ent upon  air  for  existence,  while  those  in  the  intestines  are  not. 

Factors  Influencing  Excessive  Fermentation.  —  The  factors 
influencing  excessive  fermentation  in  the  stomach  are  lack  of 
"  tone  "  and  motility  in  the  organ,  insufficient  amount  or  absence 
of  free  hydrochloric  acid  in  the  gastric  secretion,  dilation  of  the 

"  "Chemistry  of  Food  and  Nutrition,"  Sherman. 


124  DIETETICS  FOR  NURSES 

stomach,  and  an  excess  of  carbohydrate  foods  in  the  diet.  Of  the 
latter,  sucrose  and  glucose  are  especially  susceptible  to  the  action 
of  fermentative  bacteria.  Under  normal  conditions,  that  is,  in 
health,  the  conditions  prevailing  in  the  stomach  are  very  unfavor- 
able to  the  development  of  bacteria  of  the  putrefactive  type,  the 
gastric  juice  exhibiting  decided  germicidal  properties.  Then,  too, 
the  presence  of  air  acts  against  their  development.  Much  of  the 
so-called  gastric  fermentation  does  not  occur  in  the  stomach  but 
rather  in  the  duodenum. 

Bacterial  Action  in  the  Intestines.  —  In  the  lower  part  of  the 
small  and  in  the  large  intestines,  the  bacteria  of  the  anaerobic  type 
iQcrease,  conditions  more  favorable  to  their  development  existing 
there  than  farther  up  in  the  intestinal  tract.  However,  there  are 
a  great  many  bacteria  in  the  whole  of  the  small  intestine.  Those 
producing  decomposition  of  the  unabsorbed  proteins  are  especially 
prominent  in  the  colon. 

Herter  ^^  states  that  "  the  presence  in  the  colon  of  immense 
numbers  of  obligate  micro-organisms  of  the  B.  coli  type  may  be 
an  important  defense  of  the  organism  in  the  sense  that  they  hinder 
the  development  of  that  putrefactive  decomposition  which,  if  pro- 
longed, is  so  injurious  to  the  organism  as  a  whole.  We  have  in 
this  adaptation  the  most  rational  explanation  of  the  meaning  of 
the  myriads  of  colon  bacilli  that  inhabit  the  large  intestine.  This 
view  is  not  inconsistent  with  the  conception  that  under  some  con- 
ditions the  colon  bacilli  multiply  to  such  an  extent  as  to  prove 
harmful  through  the  part  they  take  in  promoting  fermentation 
and  putrefaction." 

Effect  of  Bacterial  Activity  in  the  Body.  —  In  summarizing  the 
effects  of  bacterial  action  in  the  body  it  is  found  that  with  the  ex- 
ception of  oxalic  acid,  which  is  exceedingly  injurious,  and  which, 
according  to  Herter,  results  from  the  eating  of  large  quantities  of 
meat  and  sugar,  the  products  of  fermentation  are  simply  irritating 
in  character,  while  those  resulting  from  putrefaction  are  distinctly 
toxic.  Among  the  substances  deserving  mention  under  this  head 
we  have  indol,  skatole,  cresol,  and  phenol.     These  substances  are 

"  Herter's  "Bacterial  Infections  of  the  Digestive  Tract"  (1907). 


THE  HUMAN  BODY  125 

very  soluble  and  upon  absorption  combine  with  the  sulphuric  acid 
formed  in  the  body  and  are  excreted  by  way  of  the  kidneys  where 
they  appear  in  the  urine  as  "  conjugated  sulphates,"  the  chief  of 
which  is  indican.  The  amount  of  indican  in  the  urine  is  taken  as 
a  measure  of  the  intensity  of  the  putrefaction  taking  place  in  the 
body. 

METABOLISM 

After  the  food  has  passed  through  the  process  of  digestion,  has 
been  hydrolyzed  to  the  simpler  substances  required  and  as  such  has 
been  absorbed,  the  next  step  in  its  progress  is  the  rebuilding  into 
body  material,  which  process  is  known  as  metabolism,  or  the 
building  of  lower  substances  into  higher  ones. 

Behavior  of  Carbohydrates  in  Metabolism.  —  As  Sherman  ^^ 
has  said :  "At  least  two  kinds  of  enzymes  are  believed  to  be  in- 
volved in  the  combustion  of  glucose  in  the  tissue  cells,  (1)  clearage 
enzymes,  which  split  the  molecule  into  fragments  more  easily 
oxidized,  and  (2)  oxidizing  enzymes  or  oxidases  which  stimulate 
the  oxidation  of  the  cleavage  products.  Both  kinds  of  enzymes 
are  widely  distributed  through  the  body  and  are  believed  to  be 
normal  constituents  of  all  active  cells." 

Production  of  Energy.  —  It  has  been  proved  that  the  energy 
for  external  and  internal  work  is  produced  largely  from  the  glucose 
brought  by  the  blood  and  oxidized  in  the  muscles,  the  activity  of 
the  cells  in  the  tissues,  rather  than  the  amount  of  oxygen,  deter- 
mining the  rate  of  combustion.  When  a  surplus  amount  of  car- 
bohydrate food  is  eaten,  instead  of  being  burned  it  is  stored  in  the 
liver  and  muscles  as  glycogen.  Calorimeter  experiments  have 
proved  that  when  the  supply  of  carbohydrates  is  greatly  in  excess, 
the  body  will  utilize  them  for  the  production  of  energy  in  place  of 
the  fats  in  the  diet. 

Fate  of  the  Carbohydrates.  —  After  their  oxidation  the  end  prod- 
ucts of  carbohydrates,  that  is,  the  substances  which  are  no  longer 
available  for  use  in  the  body,  leave  it  in  the  form  of  carbon  dioxide 
and  water  by  way  of  the  kidneys  (urine),  the  skin,  the  lungs,  and 
the  intestines. 

"  "Chemistry  of  Food  and  Nutrition,"  Henry  Sherman.         , 


126  DIETETICS  FOR  NURSES 

Fate  of  the  Fats.  —  The  fats  upon  absorption  are  taken  up  by 
the  lymph  vessels  instead  of  the  capillaries  and  enter  the  blood 
with  the  lymph.  According  to  various  investigators,  the  fat  which 
causes  the  turbidity  of  the  blood  plasma  at  the  height  of  absorption 
will,  as  a  rule,  disappear  after  a  few  hours,  part  of  it  being  burned 
as  fuel,  producing  "energy  for  the  internal  and  external  work  of  the 
body,  and  at  least  a  part  of  the  fats  eaten  being  rebuilt  into  body 
fat.  The  end-products  of  fat  metabolism,  like  those  of  the  carbo- 
hydrates, consist  of  carbon  dioxide  and  water,  and  leave  the  body 
by  the  same  excretory  channels. 

Protein  metabolism  is  certainly  more  complex  than  that  of  either 
of  the  other  active  organic  food  groups.  The  amino  acids  which 
are  the  products  of  protein  digestion  are  taken  up  by  the  capillary 
blood  vessels  in  the  intestinal  walls  and  are  passed  by  them  into 
the  portal  vein,  soon  to  become  available  for  the  needs  of  the 
body. 

Metabolism  of  Body  Tissues.  —  There  are  certain  autolytic 
enzymes  which  are  found  in  all  the  organs.  These  enzymes  break 
down  the  proteins  of  the  tissues  and  fluids  of  the  body  with  the 
production  of  amino  acids,  which  are  seemingly  exactly  like  those 
formed  in  digestion.  A  small  part  of  the  products  of  protein 
metabolism  is  used  as  repair  material  and  for  the  building  up  and 
strengthening  of  the  muscular  tissues,  but  the  greater  part  is 
utilized  by  the  body  as  fuel  for  the  production  of  energy. 

End  Products  of  Protein  Metabolism.  —  After  utilization  in 
the  body,  the  proteins,  like  the  other  foods,  leave  certain  waste 
products  which  indicate  to  a  greater  or  lesser  extent  the  complete- 
ness with  which  the  organism  has  made  use  of  the  food  materials. 
The  end-products  of  protein  metabolism  are :  urea,  ammonium 
salts,  purin  bodies,  and  creatinin.  These  products  leave  the  body 
chiefly  in  the  urine.  The  chief  end-product  in  man  is  urea.  This 
substance  represents  from  82-88  per  cent  of  the  total  nitrogen 
excreted  by  the  kidneys.  However,  the  less  highly  oxidized  prod- 
ucts represent  the  incomplete  products  of  protein  metabolism 
and  thus  indicate  the  changes  through  which  these  products  must 
pass  before  being  changed  into  urea.     If  for  any  reason  there  is  an 


THE  HUMAN  BODY  127 

impairment  of  the  liver  through  which  they  must  pass  and  where 
the  change  into  urea  is  accomplished,  there  will  be  a  rise  of  am- 
monia and  a  corresponding  decrease  in  the  output  of  urea  in  the 
urine.  Thus,  ammonia  is  formed  at  the  expense  of  the  urea. 
This  occurs  in  fevers,  diabetes,  and  certain  structural  diseases  of 
the  liver.  According  to  Sherman  :  ^*  ''  Normally  about  2  to  6  per 
cent  of  the  total  nitrogen  eliminated  is  in  the  form  of  ammonium 
salts,  the  amount  depending  largely  upon  the  relation  between  the 
acid-forming  and  base-forming  elements  in  the  food.*' 

Purin  Bases.  —  These  compounds  are  formed  in  the  body  as 
cleavage  products  of  nucleoproteins  or  taken  into  the  body  in  food. 
The  chief  of  these  products  are  adenin,  guanin,  hypoxanthin, 
xanthin,  and  uric  acid.  The  latter  is  the  most  highly  oxidized  of 
all  the  purin  bases  and  the  form  which  is  chiefly  eliminated  in  the 
urine. 

Formation  of  Uric  Acid.  —  The  formation  of  uric  acid  can  in  a 
measure  be  controlled  by  attention  to  the  diet,  eliminating  those 
foods  known  to  be  purin  bearing.  Normally  from  1  to  3  per  cent 
of  the  nitrogen  eliminated  will  be  in  the  form  of  uric  acid.  The 
normal  human  being  oxidizes  about  half  of  the  purins  eaten  and 
excretes  about  half,  mainly  in  the  form  of  uric  acid.  According 
to  Mendel,  the  formation  of  uric  acid  takes  place  throughout  the 
body,  and  its  partial  destruction  is  accomplished  by  the  kidneys, 
muscles,  and  liver.  The  formation  of  purins  in  the  body  and  their 
elimination  in  the  form  of  uric  acid  is  especially  significant  in  cer- 
tain pathological  conditions,  gout,  for  example,  in  which  the  body 
has  difficulty  in  eliminating  these  compounds. 

The  purin  bodies  are  both  endogenous  and  exogenous  —  that 
is,  they  may  be  brought  into  the  body  in  food  as  such,  or  they  may 
be  formed  as  a  result  of  the  metabolism  of  the  body  tissues.  For 
this  reason  the  damage  wrought  by  these  substances  may  to  a 
certain  extent  be  controlled  by  eliminating  the  purin-bearing  foods 
from  the  diet.  Flesh-foods  are  high  in  purins,  especially  the  highly 
nucleated  glandular  organs,  liver,  thymus  (sweetbreads),  etc., 
kidney,  beef,  mutton,  veal,  pork,  chicken,  turkey,  goose,  sardines, 

"  "Chemistry  of  Food  and  Nutrition,"  Sherman. 


128  DIETETICS  FOR  NURSES 

anchovies,  all  kinds  of  fish,  except  cod.  Among  the  vegetable 
foods  asparagus,  beans,  peas,  and  spinach  are  highest  in  purins. 
Boiling  extracts  much  of  the  purins  from  food.  Meat  especially 
should  be  prepared  by  this  method,  if  used  in  the  diet  of  individuals 
suffering  from  gout.  Eggs  and  milk  are  purin  free,  and  may  be 
used  freely.  Certain  substances  increase  the  difficulty  of  elim- 
inating uric  acid.  Alcoholic  beverages  for  example  are  especially 
deleterious. 

Creatinin.  —  This  end-product  of  protein  metabolism  is,  like 
uric  acid,  endogenous  and  exogenous.  It  is  one  of  the  normal 
constituents  of  the  urine.  The  quantity  is  fairly  constant  for  the 
individual,  averaging  about  0.02  gram  per  kilogram  of  body  weight 
per  day. 

SUMMARY 

Behavior  of  Food  in  Metabolism.  —  We  have  seen  in  this  brief 
history  of  the  behavior  of  the  foodstuffs  in  metabolism  just  why 
it  is  not  possible  for  a  human  being  to  exist  upon  one  kind  of 
food  alone.  The  mystery  surrounding  the  transformations  of 
the  foods  in  the  body  has  received  much  light  during  the  past 
few  years. 

End-products  of  Protein  Metabolism.  —  Take,  for  example, 
the  end-products  of  protein  metabolism.  Formerly  it  was  believed 
that  uric  acid  was  the  result  of  the  metabolism  of  all  simple  pro- 
teins ;  now  we  know  it  to  be  the  end-product  of  a  group  of  food 
substances  known  as  purins,  which  are  combinations  of  a  simple 
protein  with  a  nuclein  or  nucleic  acid,  and  since  these  sub- 
stances are  particularly  abundant  in  the  glandular  organs,  such 
as  liver  and  sweetbreads,  and  in  meat,  the  question  of  the  pro- 
duction of  uric  acid  in  the  body  resolves  itself  into  a  nutritional 
problem. 

Controlling  the  Uric  Acid  Output.  —  By  reducing  the  purin- 
bearing  foods  in  the  dietary  one  can  control  to  a  large  extent  the 
output  of  uric  acid  in  the  urine.  Ammonia,  another  end-product 
of  protein  metabolism,  is  looked  upon  as  an  index  to  the  amount 
of  excess  acid  produced  in  the  body. 


THE  HUMAN  BODY  129 

Acid-forming  and  Base-forming  Foods.  —  Mendel  ^^  states : 
"  There  are  foods  which  act  as  potential  acids  and  others  which 
function  as  bases  in  the  organism.  When  burned  up  either  in 
the  laboratory  or  in  the  body  cells,  they  have  a  preponderance 
of  acid  or  base,  as  the  case  may  be,  in  their  ash.  In  this  re- 
spect potatoes,  apples,  raisins,  and  cantaloupes,  for  example,  are 
base-forming  foods  which  depress  the  output  of  ammonia  and 
increase  the  solubility  of  uric  acid  in  the  urine,  whereas  meal, 
cereals,  and  prunes  (the  latter  with  their  content  of  benzoic  acid) 
furnish  acids  in  predominance.  Milk  is  intermediate  in  this 
respect." 

Thus  it  is  demonstrated  of  what  inestimable  value  is  Nature's 
donation  of  food  to  mankind  and  also  of  the  wonderful  way  in 
which  the  human  organism  makes  use  of  these  gifts. 

Use  of  Food  Combinations  by  Body.  —  One  chemical  combina- 
tion is  used  as  building  stones  to  repair  the  old  and  construct  the 
new  tissues  necessary  for  life's  continuance ;  others  are  utilized 
as  fuel,  not  only  to  maintain  a  normal  temperature  in  the  body 
and  prevent  us  from  freezing  to  death,  but  also  to  drive  the  engine 
which  turns  all  the  wheels  of  the  internal  mechanism ;  while  still 
others  are  used  as  regulators  of  the  body  processes  lending  alka- 
linity to  one  secretion  and  acidity  to  another ;  increasing  the  solu- 
bility and  diffusibility  of  certain  substances,  thereby  assisting  their 
passage  through  the  walls  of  the  cells.  "  As  soluble  salts  held  in 
solution  in  the  fluids  of  the  body,  giving  them  their  characteristic 
influence  upon  the  elasticity  and  irritability  of  muscle  and 
nerve."  ^^ 

The  Process  of  Osmosis  in  the  Body.  —  The  influence  exerted 
upon  the  process  of  osmosis  in  the  body  is  one  of  the  most 
important  parts  played  by  the  mineral  salts  in  metabolism. 
The  fact  that  these  chemical  substances  are  indispensable  to 
the  metabolic  processes  makes  it  necessary  for  the  nurse  to 
know    where    they    can    be    found    in    food    and    how    to    best 

"  "Newer  Points  of  View  Regarding  the  Part  Played  by  Different  Foodstuffs 
in  Nutrition,"  by  Lafayette  Mendel,  Ph.D.  Read  at  the  Sixty-fifth  Annual 
Meeting  of  the  American  Medical  Association,  June,  1914. 

1*  "  Chemistry  of  Food  and  Nutrition,"  Sherman. 
K 


130  DIETETICS  FOR  NURSES 

utilize  them  in  the  abnormal  conditions  which  from  time  to  time 
develop. 

Factors  Affecting  Metabolism.  —  The  various  factors  affect- 
ing the  metabolism  of  the  human  body,  the  age,  and  activity  of 
the  individual,  his  health  and  nervous  organization,  have  been 
dealt  with  in  the  foregoing  pages.  The  behavior  of  the  body  under 
abnormal  conditions  must  be  discussed  in  the  chapters  dealing 
with  the  different  nutritional  disorders. 


CHAPTER  VII 

THE  FOOD  REQUIREMENTS  OF  THE  BODY 

The  human  body,  as  far  as  can  be  judged,  does  not  use  one 
nutrient  to  the  exclusion  of  another,  but  science  has  proved  that 
the  best  results  are  obtained  from  diets  balanced  to  suit  the  needs 
of  the  body,  providing  the  fuel  ard  repair  materials  in  the  amounts 
which  are  calculated  to  give  the  maximum  value  with  the  minimum 
expenditure  on  the  part  of  the  organism.  The  investigators  have 
endeavored  to  standardize  the  food  requirements  of  the  body.  In 
America  these  standards  are  higher  than  in  most  of  the  other  coun- 
tries; for  example,  in  France  Gautier  recommends  the  following 
standards  for  men  with  little  muscular  work : 

Protein 107  grams 

Fat ■     65  grams 

Carbohydrates       407  grams 

which  will  provide  2640  calories  per  day. 

In  England  Playfair  recommends  the  following  standard  for 
men  of  moderate  activity : 

Protein 119  grams 

Fat 51  grams 

Carbohydrates 531  grams 

In  Germany  the  standard  suggested  by  Voit  is  low  in  fat  and 
high  in  carbohydrates.  This  was  probably  so  arranged  because 
the  carbohydrates  were  cheaper  than  the  fats.  Voit's  standard  for 
men  at  moderate  muscular  work : 

Protein 118  grams 

Fat 56  grams 

Carbohydrates 500  grams 

Atwater's  standards  for  American  dietaries  are  more  liber£il 
than  any  of  the  others.    He  has  suggested  "  that  the  standard 

131 


132 


DIETETICS  FOR  NURSES 


must  vary  not  only  with  the  conditions  of  activity  and  environ- 
ment, but  also  with  the  nutritive  plane  at  which  the  body  is  main- 
tained." ''  A  man  may  live  and  work  and  maintain  bodily  equi- 
librium on  either  a  higher  or  a  lower  nitrogen  level,  or  energy  level. 
One  essential  question  is,  what  level  is  most  advantageous  ?  The 
answer  to  this  must  be  sought  not  simply  in  metabolism  experi- 
ments and  dietary  studies,  but  also  in  broader  observations  regard- 
ing bodily  and  mental  efficiency  and  general  health,  strength,  and 
welfare."  ^ 

TABLE  XIV 

atwater's  standard  for  men  and  women  with  varying 
muscular  activities  2 


• 

Protein 
Grams 

Fuel  Value 
Calories 

Man  with  hard  muscular  work 

Man  with  moderately  active  muscular  work 
Man  at  sedentary  or  woman  with  moderately 
active  work 

150 
125 

100 

90 

4150 
3400 

2700 

Man  without  muscular  exercise  or  woman  with 
light  to  moderate  work 

2450 

FACTORS  DETERMINING  THE   FOOD  REQUIREMENTS  OF  MAN 

There  are  a  number  of  factors  exerting  more  or  less  influence 
upon  the  food  requirements  of  the  body,  namely  :  age,  sex,  height, 
size  of  the  body,  muscular  activity,  etc.  Of  these  factors,  the  age 
and  muscular  activities  probably  play  the  most  important  parts. 
From  birth  to  the  twenty-fifth  year  the  factor  of  growth  is  of  para- 
mount importance.  During  this  period  the  organs  of  the  body 
must  be  furnished  material  for  growth  and  development  and  the 
body  itself  with  material  for  its  increase  in  weight  and  height. 
When  the  supply  of  food  is  not  commensurate  with  the  rate  of 

1  "Chemistry  of  Food  and  Nutrition,"  by  Sherman. 

2  Farmers'  Bulletin,  No.  142,  U.  S.  Department  of  Agriculture.  "The  Demands 
of  the  Body  for  Nourishment  and  Dietary  Standards,"  Fifteenth  Report,  Storrs 
(Conn.)  Agricultural  Station. 


THE  FOOD  REQUIREMENTS  OF  THE  BODY     133 

metabolism,  growth  and  development  cease  and  sooner  or  later 
evidences  of  disturbed  nutritional  and  metabolic  processes  become 
apparent. 

Daily  Gain.  —  In  estimating*  the  relative  daily  gain  in  body 
weight  of  children  of  different  ages,  Mendel  ^  gives  the  following 
table : 

TABLE   XV 

In  the  first  month,  about 1.00  per  cent 

At  the  middle  of  the  first  year        0.30  per  cent 

At  the  end  of  the  first  year 0.15  per  cent 

At  fifth  year 0.03  per  cent 

Maximum  in  later  years  for  boys        ....  0.07  per  cent 

Maximum  in  later  years  for  girls 0.04  per  cent 

Use  of  Chemical  Combinations.  —  Thus  it  is  seen  that  the  period 
during  which  the  growth  is  most  rapid  is  during  the  earlier  months 
of  life.  "  The  growing  body  requires  protein  with  which  to  build 
body  tissues,  muscles,  etc.,  while  carbohydrates  and  fats  are  used 
as  fuel.  It  is  obvious,  therefore,  that  more  protein  or  nitrogen 
must  be  ingested  than  excreted  in  order  that  the  needs  of  the  grow- 
ing tissues  may  be  supplied.  The  skeleton,  teeth,  etc.,  in  the  same 
way  require  mineral  salts  for  their  growth,  and  more  salts  must  be 
ingested  in  the  food  than  are  lost  in  the  excreta.  These  salts  which 
are  retained  in  the  body  are  used  to  build  up  the  new  bone. 

Retention  of  Nitrogen  in  Infancy.  —  When  the  baby  is  gaining 
in  weight  and  strength  there  is  a  retention  of  both  nitrogen  and 
salts,  arid  when  the  baby  is  not  gaining  there  may  be  a  loss  of  both 
of  these  bodies ;  when  one  is  retained  in  the  body  the  other  is  apt 
to  be  retained."  ^  After  the  body  has  reached  maturity,  that  is, 
after  the  stature  has  reached  its  full  height  and  development, 
there  still  remains  the  maintenance  factor.  There  is  never  a  period 
of  life  during  which  repair  foods  are  not  necessary.  The  broken- 
down  tissues,  due  to  the  wear  and  tear  of  intracellular  work,  must 
be  replaced  with  new  material  in  order  that  the  work  may  go  on 
without  permanently  injuring  the  health  of  the  individual.    These 

3  "Childhood  and  Growth,"  p.  18,  by  Lafayette  Mendel. 

*  "  Diseases  of  Nutrition  and  Infant  Feeding, "  by  Morse  and  Talbot. 


134  DIETETICS  FOR  NURSES 

repair  foods,  as  shown  in  the  beginning  of  this  text,  consist  of 
proteins. 

Age.  —  Children  have  a  greater  food  requirement  in  proportion 
to  their  weight  than  adults.  This  is  not  only  in  proportion  to 
their  weight  but  to  their  surface  area.  According  to  Sherman  ^ 
"  the  total  metabolism  of  a  two-year-old  child  at  rest,  weighing 
twenty-five  pounds,  is  half  as  great  as  that  of  an  adult  weighing 
six  times  as  much.  Hence  the  food  requirement  per  unit  of 
weight  is  three  times  as  great  for  the  child  as  for  the  man  at 
rest." 

Sex.  —  Women's  weight  averages  about  0.8  as  much  as  a  man's, 
consequently  if  she  is  equally  as  active  her  food  requirement  may 
be  computed  as  .8  of  his. 

Langworthy  •  estimates  the  average  food  requirements  for  per- 
sons of  moderate  activity  as  3000  calories  per  day  —  100  grams  or 
400  calories  of  which  must  be  obtained  from  protein  to  provide 
for  the  nitrogen  requirements  of  the  body.  Dr.  Langworthy  sug- 
gests that  for  men,  such  as  mechanics,  who  have  greater  muscular 
activity  and  perform  moderately  active  labor,  the  standard  of 
food  requirements  be  raised,  for  example : 

For  food  purchased  115  grams  of  protein  and  3800  Energy 
Calories. 

For  food  eaten  105  grams  protein  and  3500  Energy  Calories. 

Dr.  Sherman  ^  suggests  making  use  of  the  following  factors  in 
computing  the  food  requirements  for  the  different  ages,  namely : 
The  factor  1  for  man  and  0.8  for  women  and  boys  between  the 
ages  of  14  and  17  years.  For  girls  of  like  ages  the  factor  .7.  For 
children  from  10  to  13  years  he  suggests  .6  as  a  factor,  for  those 
between  the  ages  of  6  and  9,  .5,  and  for  those  from  2  to  5  years,  .4. 
For  all  children  under  2  years,  the  factor  .3.  These  factors  are 
based  upon  the  requirements  of  men  engaged  in  moderately  active 
work.  According  to  Sherman  a  woman  of  weight  and  activity 
equal  to  man  would  require  as  much  food  to  cover  her  energy  re- 
's "Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 

•5  "Food  and  Diet  in  United  States."  Reprinted  from  the  "Year  Book  of  the 
U.  S.  Department  of  Agriculture  for  1907." 

'  "Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


THE  FOOD  REQUIREMENTS  OF  THE  BODY     135 

quirements  as  he.     The  requirements  of  either  must  necessarily 
vary  with  the  degree  of  activity. 

The  following  tables,  selected  from  estimates  made  by  Atwater 
and  Benedict,  Von  Noorden,  and  Sherman,  are  given  to  show  the 
variations  in  the  food  requirements  of  the  different  ages  accord- 
ing to  the  degree  of  activity : 


TABLE   XVI 

18 


Man  sleeping      .     .     .     .     .     . 

Man  sitting  at  rest      .... 

Man  at  light  muscular  activity 
Man  at  active  muscular  activity- 
Man  at  severe  muscular  activity 
Man  at  very  severe  muscular  activity 


65  calories  per  hour 
100  calories  per  hour 
170  calories  per  hour 
290  calories  per  hour 
450  calories  per  hour 
600  calories  per  hour 


119 

Men  and  women  of  young  to  middle 

age  at  complete  rest 30-35  calories  per  kilo,  per  day 

Men  and  women  of  young  to  middle  age 

at  hght  exercise 35-40  calories  per  kilo,  per  day 

Men  and  women  of  young  to  middle  age 

at  moderate  exercise 40-50  calories  per  kilo,  per  day 

Men  and  women  of  young  to  middle  age 

at  hard  muscular  exercise      ....     45-60  calories  per  kilo,  per  day 


IIIio 


Boys  14-17  years  will  require  .     . 
Girls  14-17  years  will  require  .     . 
Children  of  10-13  years  will  require 
Children  of    6-9    years  will  require 
Children  of    2-5    years  will  require 
Children  of    1-2    years  will  require 


2500-3000  calories  per  day 
2200-2600  calories  per  day 
1800-2200  calories  per  day 
1400-2000  calories  per  day 
1200-1500  calories  per  day 
900-1200  calories  per  day 


Exercise.  —  All  of  the  investigators  agree  that  exercise  is  the 
most  potent  factor  affecjting  the  food  requirements  of  man,  except 
during  that  period  in  which  the  body  must  grow  and  develop. 
In  infancy  the  rapid  rate  of  metabolism  necessitates  a  larger  pro- 
portion of  food  in  proportion  to  weight  than  in  later  years.  But 
even  in  childhood  exercise  exerts  a  most  telling  influence  upon  the 


8  Atwater  and  Benedict's  estimates. 


'  Von  Noorden's  estimates. 


10  Sherman's  estimates. 


136  DIETETICS  FOR  NURSES 

amount  of  food  necessary  to  keep  the  body  in  good  running  order ; 
for  instance,  little  boys  generally  exhibit  a  greater  muscular  activity 
than  little  girls  and  even  in  the  cases  where  the  age  and  weight  of 
the  children  are  identical  the  muscular  tension  of  the  boys  is 
generally  found  to  be  greater  than  that  of  the  girls.  Exercise 
does  not  break  down  a  muscle  as  some  imagine,  but  builds  it  up 
both  in  size  and  in  strength.  In  this  way  the  protein  is  stored 
in  the  body  as  such. 

After  fifty  the  muscular  activity  as  a  rule  decreases :  the  desire 
for  heavy  exercise  becomes  perceptibly  less.  In  many  cases  the 
diet  habits  acquired  when  the  amount  of  exercise  was  greater  con- 
tinue to  exist,  consequently  when  the  amount  of  food  eaten  is 
greater  than  the  expenditures  of  the  body  there  will  often  be  an 
accumulation  of  fat  which  increases  the  body  weight  of  the  in- 
dividual. A  reasonable  increase  in  the  adipose  tissues  is  not  objec- 
tionable, but  when  the  organism  shows  evidences  of  nutritional 
disturbances  due  to  the  over-supply  of  food  and  a  lack  of  muscular 
activity,  the  diet  should  be  immediately  adjusted  to  more  ade- 
quately meet  the  changed  conditions. 

Transformation  of  Food  in  the  Body.  —  It  has  been  proved  that 
as  far  as  Nature  is  concerned  there  is  no  difference  made  between 
any  of  the  organic  foodstuffs  as  a  source  of  energy,  but,  as  Rubner 
expressed  it :  "  Mute  and  still,  by  night  and  by  day,  the  labor  goes 
on  in  the  workshops  of  life  "  and  science  has  proved  that  material 
for  the  maintenance  of  life's  workshops  can  be  derived  from  pro- 
tein foods  only,  since  this  chemical  combination  alone  contains  the 
nitrogen  which  is  absolutely  necessary  to  replace  that  which  is 
constantly  being  used  up  in  the  body  processes.  The  body  must 
be  kept  in  what  is  known  as  "  nitrogen  equilibrium  "  if  life  is  to 
continue.  According  to  Lusk  "  an  infant  has  the  power  of  trans- 
forming 40  per  cent  of  the  protein  in  its  food  into  new  structural 
machinery,  the  architecture  of  which  depends  upon  the  regroup- 
ing of  the  individual  units  formerly  in  the  protein  of  milk.  Thus 
new  proteins  are  built  Vv^hose  internal  arrangement  is  dependent 
upon  local  conditions  in  the  various  organs  of  the  child."  ^^ 

"  "Basis  of  Nutrition,"  p.  18,  Lusk. 


THE  FOOD  REQUIREMENTS  OF  THE  BODY     137 

Protein  Needs  of  the  Body.  —  The  experiments  carried  on  by  all 
of  the  investigators  prove  that  there  is  a  constant  necessity,  as  has 
already  been  stated,  for  a  replenishment  of  the  proteins  in  the  body 
and  that  a  definite  amount  is  necessary  in  the  food  to  protect  the 
body  from  a  loss  of  its  own  proteins.  It  has  likewise  been  proved 
that  these  body  proteins  are  spared  more  effectually  when  there  is 
an  ample  amount  of  fuel  foods  allowed  for  the  energy  expenditures. 
Proteins  Producing  Growth.  —  Formerly  it  was  believed  that 
all  proteins  had  the  ability  to  produce  growth,  but  in  late  years 
this  theory  has  been  exploded.  Osborne  and  Mendel  have  been 
making  extensive  experiments  in  the  feeding  of  the  various  pro- 
teins. They  found  that  while  some  of  these  substances  produced 
normal  growth  and  development  in  the  animals  to  which  they  were 
fed,  others  did  not.  Upon  further  investigation  it  was  proved  that 
some  of  the  proteins  did  not  contain  all  of  the  protein  units  and 
some  of  them  could  not  be  transformed  in  the  body  to  form  com- 
plete protein,  hence  the  animals  fed  upon  these  incomplete  pro- 
teins lost  weight  and  eventually  died  unless  the  diet  was  changed. 
Examples  of  the  incomplete  proteins  may  be  found  in  gelatine,^ 
gliadin  (one  of  the  proteins  of  wheat),  and  zein,  the  alcohol-soluble 
protein  which  forms  over  half  the  protein  content  of  Indian  corn. 
Source  of  Growth-producing  Proteins.  —  The  complete  proteins 
or  proteins  capable  of  producing  growth  are  found  in  the  casein  of 
milk  or  albumen  of  eggs,  and  the  proteins  of  meat  and  the  glutenin 
of  wheat.  These  so-called  "  complete  proteins  "  provide  for  both 
the  maintenance  and  the  growth  factors  in  the  body,  as  well  as 
for  much  of  the  energy  expended.  Thomas  has  estimated  that  the 
following  minimum  amounts  are  required  to  protect  the  body  pro- 
teins from  loss :  ^' 

TABLE  XVII 

Meat  protein 30  grams 

Milk  protein 31  grams 

Rice  protein 34  grams 

Potato  protein  38  grams 

Bean  protein 54  grams 

Bread  protein 76  grams 

Indian  corn  protein 102  grams 

^>  "It  has  long  been  known  that  gelatine  as  a  sole  protein  food  does  not  suffice 
for  the  maintenance  of  nitrogen  equilibrium."     Sherman. 
"  Table  taken  from  Lusk's  "Basis  of  Nutrition,"  p.  20. 


138  DIETETICS  FOR  NURSES 

Thus  it  is  seen  that  distinction  is  made  between  the  animal  and 
the  vegetable  proteins ;  more  of  the  latter  is  required  to  prevent 
loss  of  body  protein  than  of  the  former.  In  the  experiments  with 
white  rats  Osborne  proved  that  when  he  fed  zein  the  rat  lost 
weight  and  died  unless  a  change  was  made  and  the  zein  was  re- 
placed by  other  proteins  capable  of  overcoming  the  condition. 

As  a  Protection  against  Cold.  —  Lusk  states  that  protein  has 
one  property  out  of  all  proportion  to  that  possessed  by  the  other 
foodstuffs  :  it  largely  increases  the  production  of  heat  in  the  body 
and  individuals  kept  on  a  diet  low  in  protein  are  apt  to  suffer 
intensely  with  the  cold.  He  further  states  that  "  a  good  piece  of 
beefsteak  or  roast  beef  will  put  the  heat  production  on  a  higher 
level  and  a  person  going  out  of  doors  on  a  cold  day  after  a  meal 
high  in  protein  does  not  feel  the  cold."  This  is  probably  the  reason 
why  one  instinctively  avoids  meat  when  the  weather  is  hot. 

SUMMARY 

In  summarizing  the  various  factors  which  affect  the  food  re- 
quirements of  all  ages,  we  find  that  age,  appetite,  and  sleep, 
type  of  occupation,  and  the  manner  of  living  all  exert  a  certain 
amount  of  influence.  The  man  who  sits  all  day  at  his  desk  may 
work  just  as  hard  as  the  clerk  who  does  his  bookkeeping  stand- 
ing up,  but  the  latter  will  require  more  food  to  meet  the  require- 
ments of  his  body  than  the  man  sitting  down.  The  short  fat  man 
will  require  less  food  than  the  tall  thin  one  even  if  their  weight 
is  practically  the  same.  The  man  who  does  manual  labor 
out  of  doors  uses  up  more  food  material  than  the  man  who  labors 
within  four  walls.  In  health  the  appetite  is  a  fairly  good  guide  to 
the  amount  of  food  one  needs,  unless  habit  has  caused  the  indi- 
vidual to  constantly  consume  more  than  the  body  calls  for.  If 
the  digestion  is  good  and  the  weight  normal,  that  is,  if  there  is  no 
great  fluctuation  either  of  gain  or  loss  of  weight  during  the  year, 
it  is  fairly  certain  that  the  amount  of  food  ingested  is  commen- 
surate with  the  energy  expenditures  of  the  body.  When,  however, 
there  are  evidences  of  disturbed  metabolism  —  gout,  for  example 
—  it  is  well  to  observe  Nature's  danger  signal  and  reduce  the  diet 


THE  FOOD  REQUIREMENTS  OF  THE  BODY     139 

until  it  simply  covers  the  needs  of  the  body  instead  of  catering  to 
the  whims  of  the  appetite. 

Age  and  Weight.  —  As  has  already  been  stated,  there  are  cer- 
tain points  to  be  kept  in  mind  in  attempting  to  provide  an  ade- 
quate diet  for  the  human  machine ;  First,  the  age  and  weight.  The 
gain  during  infancy  should  be  steady  —  an  allowance  of  40  cal- 
ories per  pound  of  body  weight  to  cover  the  energy  requirements 
and  4  protein  calories  per  pound  to  cover  the  nitrogen  needs. 
During  the  second  and  third  years  the  energy  requirements  will  be 
covered  by  30  to  40  calories  per  pound  and  the  nitrogen  needs  by 
3  to  4  protein  calories  per  pound.  From  the  fifth  to  the  eighth 
year  the  nitrogen  needs  continue  to  be  covered  by  3  to  4  protein 
calories  per  pound  and  the  energy  requirements  by  35  to  37  calo- 
ries per  pound  during  the  fifth  year ;  32  to  34  calories  per  pound 
during  the  seventh  year.  After  the  body  has  reached  its  full 
development  its  requirements  will  be  met  if  sufficient  protein  is 
provided  to  cover  its  maintenance  needs  and  if  the  energy  cal- 
ories are  regulated  according  to  the  amount  of  exercise  taken, 
keeping  in  mind  that  the  energy  requirements  of  a  man  at  rest 
(sitting)  will  be  about  2000  calories  per  day  and  that  exercise, 
especially  that  taken  in  the  open  air,  raises  the  energy  needs  of 
the  body. 

Guides  to  Amounts  and  Tjrpes  of  Food.  —  In  the  foregoing 
pages  the  standards  to  be  used  as  guides  as  to  the  amounts  and 
tjrpes  of  food  have  been  given.  But  the  nurse  must  remember 
that  these  standards  are  not  infallible,  but  are  subject  to  a  certain 
amount  of  change  according  to  the  physical  condition  of  the 
individual. 

Metabolism  in  Normal  and  Abnormal  Conditions.  —  In  ab- 
normal conditions  the  metabolism  of  the  foodstuffs  often  remains 
good,  but  the  type  of  the  disease  renders  it  unwise  and  inadvisable 
to  put  too  much  strain  upon  certain  organs.  Hence  the  food  must 
be  selected  with  this  point  in  view.  In  these  cases,  however,  it  is 
the  physician,  not  the  nurse,  who  formulates  the  diet,  but  the 
nurse  must  be  prepared  to  recognize  any  deviation  from  the  normal 
behavior  of  food  in  the  body  by  the  symptoms  which  develop. 


CHAPTER  VIII 

METHODS   OF   FEEDING   IN   NORMAL   AND 
ABNORMAL  CONDITIONS 

There  are  several  methods  of  feeding  which  have  been  adopted 
to  meet  the  needs  of  the  individual  under  various  conditions : 
Feeding  by  mouth,  gavage  or  forced  feeding,  rectal  feeding 
(nutrient  enemata),  and  inunction. 

Feeding  by  Mouth.  —  The  first  method  is  the  one  used  in  health 
and  in  the  majority  of  abnormal  conditions.  In  cases  where  there  is 
a  certain  abnormal  development  of  the  mouth  or  throat,  and  in  some 
cases  of  insanity  or  unconsciousness,  where  for  some  reason  it  is  im- 
possible for  the  individual  to  swallow,  this  method  cannot  be  used. 

Forced  Feeding.  —  With  very  young  children  and  babies, 
gavage  or  forced  feeding  is  found  at  times  to  be  necessary.  In 
these  cases  a  small  rubber  catheter  is  introduced  into  the  stomach 
through  the  nostrils  and  the  milk  or  other  fluid  poured  through 
the  tube.  In  unconscious  or  insane  patients  it  is  often  found 
necessary  to  insert  a  gag  (a  cork  will  serve  the  purpose)  between 
the  teeth  to  prevent  the  biting  of  the  tube  when  it  is  inserted 
through  the  mouth  into  the  stomach. 

Food  Used  for  Forced  Feeding.  —  The  food  in  these  cases  con- 
sists of  reenforced  soups,  milk  gruels,  or  nutrient  beverages,  not 
more  than  six  or  eight  ounces  given  at  one  time.  Finely  chopped 
meat  and  vegetable  purees  have  been  given  in  this  way  when  the 
digestion  of  the  patient  was  not  impaired,  but  when  conditions 
rendered  it  necessary  to  resort  to  this  method  of  feeding. 

Technique  of  Gavage.  —  The  apparatus  used  in  gavage  consists 
of  a  moderate  sized  soft  rubber  tube  to  which  is  attached  a  rubber 
or  glass  funnel  and  a  "  pinch  cock."  The  tube  should  be  filled 
with  water  to  prevent  air  entering  the  stomach  and  causing  pain 
or  discomfort.  In  certain  cases  the  patient  refuses  to  swallow  the 
tube  and  it  will  be  found  necessary  to  use  some  means  to  force 
the  passage  if  the  throat  is  shut  off.     By  closing  the  nostrils  the 

140 


METHODS  OF  FEEDING  141 

patient  will  be  obliged  to  breathe  through  the  mouth,  thus  open- 
ing the  passage  into  the  throat  through  which  the  tube  may  be 
quickly  slipped.  In  certain  abnormal  conditions  the  gastric  organ 
is  so  badly  impaired  as  to  render  it  impossible  for  the  patient  to 
retain  food  taken  in  by  way  of  the  mouth.  It  is  often  found  that 
food  introduced  into  the  stomach  by  means  of  the  "  stomach  tube  " 
will  be  retained  and  utilized  which  otherwise  would  be  rejected. 
It  is  disagreeable,  however,  and  should  only  be  used  when  it  is 
impossible  to  feed  otherwise. 

Rectal  feeding  is  used  when  the  other  organs  of  digestion  are 
impaired  to  such  an  extent  as  to  render  the  need  of  more  food 
obligatory.  Many  investigators  believe  that  rectal  feeding  is 
absolutely  useless,  while  others  have  firm  faith  in  its  eflScacy. 

Technique  of  Rectal  Feeding.  —  The  rectum  should  be  cleansed 
by  flushing  with  a  soapsuds  enema  one  hour  before  nutrient  enema 
is  given.  This  should  be  done  once  a  day,  in  the  morning.  The 
cleansing  enema  may  be  either  soapsuds,  a  solution  of  bicarbonate 
of  soda,  or  boric  acid  (1  teaspoonful  to  the  pint),  or  a  saline  solu- 
tion. When  there  is  much  mucus,  or  if  the  rectum  is  inflamed, 
the  soda  or  boric  acid  solution  may  be  more  soothing  than  the 
saline  or  soapsuds  enema.  After  one  hour's  rest  the  patient  should 
be  given  a  nutrient  enema. 

The  method  of  administering  nourishment  through  the  rectum 
is  important.  A  nutrient  enema  injected  only  into  the  lower 
bowel  not  only  does  no  good,  but  may  actually  cause  a  good  deal 
of  unnecessary  discomfort  to  the  patient. 

Temperature  of  Enema.  —  Care  must  be  taken  not  to  have  the 
temperature  of  the  nutrient  enema  too  hot  or  too  cold  or  it  will 
be  promptly  rejected.  The  patient  is  placed  on  the  side  with 
one  knee  flexed ;  the  solution  is  poured  into  a  fountain  sjrringe 
bag  or  an  enamel  container  (heat  the  container  before  pouring  the 
solution  into  it  or  the  latter  will  be  chilled) .  The  bag  or  container 
has  attached  to  it  a  rubber  tube  with  a  cock  adjusted  so  that  only 
a  small  stream  will  flow  in  at  a  time.  To  the  end  of  this  tube  a 
rubber  rectal  tube  or  catheter  —  1  cm.  (about  ^  inch)  — is  attached. 
This  should  be  well  greased  (do  not  use  glycerin  as  this  substance 


142  DIETETICS  FOR  NURSES 

is  irritating  to  the  mucous  lining  of  the  rectum) .  The  liquid  should 
be  allowed  to  fill  the  tube  before  it  is  inserted  into  the  rectum, 
to  prevent  any  air  passing  in  with  it.  The  tube  should  be  inserted 
with  a  gentle  twisting  movement,  using  very  little  force  or  the 
tender  mucous  membranes  will  be  injured.  Insert  the  tube  twelve 
or  more  inches,  since  the  solution  is  more  completely  absorbed  if 
given  high  up  in  the  bowel.  The  bag  containing  the  solution 
should  be  held  only  a  few  inches  higher  than  the  rectum,  thus 
allowing  only  a  small  stream  to  pass  in  and  allowing  an  air  space 
above  the  stream  for  the  passage  of  gas  which  may  be  accumulated 
in  the  upper  part  of  the  rectum.  The  tube  should  be  allowed  to 
remain  in  the  rectum  for  fifteen  or  twenty  minutes,  then  very 
gently  withdrawn  to  prevent  the  liquid  from  being  rejected.  A 
pad  of  gauze  may  be  pressed  against  the  anus  to  assist  the  patient 
in  retaining  the  enema.  It  is  well  to  divert  the  attention  of  the 
patient  also,  to  further  assist  her  in  retaining  the  liquid. 

Duration  of  Rectal  Feeding.  —  Rectal  feeding  cannot  be  sub- 
stituted for  a  great  length  of  time,  first,  because  the  patient  can- 
not absorb  suflficient  nourishment  in  this  way  to  fully  cover  the 
body  requirements,  and,  second,  because  the  rectum  becomes 
more  or  less  sensitive  and  will  reject  the  liquid  before  it  has  an 
opportunity  to  be  absorbed.  From  three  to  four  nutrient  enemas 
a  day  is  about  the  limit  for  the  average  patient.  Between  the 
nutrient  enemas  it  is  advisable  to  give  one  of  saline  solution. 

The  following  regime  is  practiced  during  the  "  Total  Abstinence 
Period  "  in  the  treatment  of  gastric  ulcer :  7  a.m.,  cleansing  enema ; 
8  A.M.,  nutrient  enema;  1  p.m.,  nutrient  enema;  3  p.m.,  saline 
enema;  6  p.m.,  nutrient  enema.  One  saline  and  one  nutrient 
enema  may  be  given  during  the  night  if  the  patient  is  very  weak. 
She  should  not  be  wakened,  however,  to  be  given  the  enema. 

Feeding  by  Inunction.  —  This  method  consists  in  the  rubbing 
into  the  body  of  certain  nutrient  oils,  such  as  olive  oil,  cocoanut 
oil,  cocoa  butter,  etc.  It  is  of  little  value,  but  is  occasionally  re- 
sorted to  with  very  much  emaciated  and  underfed  infants,  when 
digestional  disorders  make  it  impossible  to  introduce  enough  food 
by  mouth  to  cover  the  needs  of  the  body. 


METHODS  OF  FEEDING  143 

Nutrient  Enemas  ^ 

No.  1.    Milk  and  Egg 
6  oz.  milk  1  egg  J  oz.  normal  saline  solution 

1  tsp.  pure  peptone  (this  may  be     1  tube  peptonizing  powder  dis- 
omitted)  solved  in  1  tbs.  water 

Mix  thoroughly  and  peptonize  at  a  temperature  of  110°  F.  for 

1  hour. 

No.  2 

8  oz.  milk  3  eggs  3  grains  table  salt 

No.  3 
8  oz.  milk  2  oz.  glucose  (grape  sugar) 

No.  4.    Singer's  Enema 
125  gm.  (about  4  oz.)  milk  1  or  2  egg  yolks 

125  gm.  (about  4  oz.)  wine  Salt 

1  tsp.  Witte's  peptone 

No.  5.  Boas  Enema 
250  c.c.  (8  oz.)  milk  1  tbs.  of  red  wine 

2  egg  yolks  1  tbs.   "Kraftmehl"  Health 
Small  quantity  of  salt  Flour 

No.  6. 
6  oz.  bouillon  .      1  egg  yolk 

4  oz.  red  wine  1  to  2  tsp.  dry  peptones 

No.  7.    Milk  and  Starch  Enemas  —  Von  Leube 
250  c.c.  (about  8  oz.)  milk  70  grains  starch 

Malted  Milk  Enema 
Dissolve  1  oz.  of  malted  milk  in     1  egg  and  |  tsp.  salt  or  }  oz. 
8  oz.  of  hot  water  saline  solution 

Normal  Saline  Solution 
1  dram  sodium  chloride  1  pt.  (16  oz.)  water, 

(common  salt)  (boiled) 

1  "Diet  in  Disease,"  by  Freidenwald  and  Ruhrah  and  other  sources. 


144 


DIETETICS  FOR  NURSES 


TABLE 
COMPOSITION   AND   FUEL  VALUE    OF   MOST    OF 


Material  * 


Almonds  .  .  . 
Apples  .  .  . 
Arrowroot  .  . 
Asparagus,  fresh 
Asparagus,  canned 


B 
Bacon 

Bananas,  E.  P.2      .     .     .     . 

Barley,  pearled 

Barley  flour 

Bass 

String  beans 

Butter  beans 

Beef  broth 

Beef  broth 

Beef  soup ' 

Beef  juice 

Beef  marrow 

Beef  steak  (porterhouse) 

Sirloin 

Top  of  round 

Roast  beef,  second  cut     .     . 
Roast  beef,  second  cut     .     . 

Bluefish 

Brandy     

Bran 

Bread 

Bread 

Bread  crumbs 

Bread,  graham 

Bread,  gluten  * 

Maryland  biscuit  (Southern 
beaten  biscuit)    .     .     .     . 


Weight 


I  oz. 


^ 

5.5  oz 
1  oz 
4  oz 
4  oz 


oz. 

oz. 

oz. 

oz. 

oz. 

oz. 

oz. 
1  oz. 
6oz. 
6oz. 

oz. 

oz. 

oz. 

oz. 

oz. 


1 

i 

2 

3 
3 
3 

2  oz. 
1  oz. 
3oz. 
\  oz. 

2ioz. 

1  oz. 
12  oz. 

5  oz. 

1  oz. 

1  oz. 

I'oz. 


Measure 


6 


1  medium  size    . 

2  tablespoonfuls 
6  stalks      .     .     . 


2  shces .     .     .     . 

1  medium  .     . 

2  tablespoonfuls 
1  tablespoonful  . 
1  serving  .  .  . 
1  serving   .     .     . 

1  serving    .     .     . 

2  tablespoonfuls 
1  cup     .     .     .     . 

1  cup     .     .     .     . 

2  tablespoonfuls 
1  tablespoonful  . 
1  serving  .  .  . 
1  serving  .  .  . 
1  serving  .  .  . 
1  slice  .  .  .  . 
1  thin  slice     .     . 


Nitrogen 


1    tablespoonful,  14.17 

grams 

1  cup 

1  slice,  \  in.  thick   .     . 

1  loaf 

1  cup 

1  slice 

1  sUce,  \ 


thick 


2  small  biscuits 


.48 
.09 

.33 

.28 


.35 
.20 
.39 
.24 

2.85 
.31 

1.28 

0.1 

0.5 

1.18 
.22 
.05 

2.98 

2.57 

2.75 

1.84 
.91 

2.60 


1.25 
.42 

5.04 

2.08 
.40 

1.34 

.38 


*  All  determinations  allow  28.35  grapas  to  the  ounce. 

All  calculations  are  made  using  the  factor  4  calories  for  protein,  4  calories  for 
carbohydrates  and  9  calories  for  fats. 

1  The  materials  are  measured  in  standard  8-ounce  measuring  cups,  or  table- 
spoons. The  measures  are  exactly  level  unless  otherwise  stated.  In  calculating 
beverages  containing  alcohol,  it  is  necessary  to  know  the  percentage  of  alcohol  con- 


METHODS  OF  FEEDING 


145 


XVIII 

THE   FOODS  USED   IN   THE   INVALID    DIETARY 


Proteins 

Fats 

Carbohydrates 

Fuel 
Value 

% 

Gm. 

% 

Gm. 

% 

Gm. 

21.0 

2.975 

54.9 

7.78 

17.3 

2.45 

91.7 

0.4 

.6 

0.5 

.77 

14.2 

22.2 

98.3 

— 

— 

— 

— 

69.2 

19.6 

78.4 

1.8 

2.04 

0.2 

.24 

3.3 

3.72 

25.2 

1.5 

1.72 

0.1 

.12 

2.8 

3.16 

20.6 

7.8 

2.2 

48.4 

13.7 

132. 

1.3 

1.25 

0.6 

.59 

22.0 

21.84 

97.6 

8.5 

2.41 

1.1 

.31 

78.0 

22.05 

100.7 

10.4 

1.48 

2.2 

.31 

72.6 

10.31 

49.9 

21.0 

17.8 

2.8 

2.37 

— 



92.5 

2.3 

1.95 

2.7 

2.29 

7.4 

6.29 

34.45 

9.3 

7.9 

0.6 

.51 

29.2 

24.7 

134.9 

1.8 

0.6 

0.1 

0.3 

— 

— ■ 

2.7 

2.2 

3.7 

0.1 

.18 

— 

— 

16.3 

4.3 

7.4 

3.6 

6.1 

1.1 

1.8 

42.9 

4.9 

1.39 

.6 

.17 

— 

— 

7. 

2.2 

.31 

92.4 

13.1 

— 

— 

119.1 

22.0 

18.63 

20.4 

17.34 

. 

— 

230.5 

19.0 

16.08 

18.5 

15.72 

— 

— 

205.8 

20.3 

17.2 

13.6 

11.5 

— 

— 

172.3 

20.2 

11.5 

8.4 

4.8 

— 

— . 

89.2 

20.1 

5.7 

8.5 

2.4 

— 

— 

44.4 

19.6 

16.6 

1.2 

1. 

— 

— 

75.4 









, 



42. 

11.0 

7.8 

2.1 

1.5 

61.2 

43.4 

218. 

9.2 

2.6 

1.2 

.34 

52.6 

14.9 

73. 

9.3 

31.5 

1.2 

4.08 

52.6 

178.8 

876. 

9.2 

13. 

1.2 

1.70 

52.5 

74.5 

405.3 

8.8 

2.5 

1.8 

.51 

51.9 

14.7 

73. 

29.7 

8.4 

1.1 

.30 

30.0 

8.5 

70.3 

8.4 

2.38 

5.6 

1.5 

60.0 

17. 

91.7 

tained  therein.    Alcohol  has  a  fuel  value  of  7  calories  per  gram.     (Whether  thia 
heat  ia  available  for  the  needs  of  the  body  is  still  a  question.) 

2  Edible  portion. 

3  Beef  soup  is  not  so  thoroughly  strained  or  so  well  skimmed  as  broth. 

*  Gum  gluten  has  a  smaller  percentage  of  starch  than  ordinary  gluten  flour. 


146 


DIETETICS  FOR  NURSES 


TABLE 


Material 


B 

Butter 

Butter 

C 

Carrots 

Carrots 

Cauliflower 

Cauliflower 

Celery 

Clam  bouillon 

Clam  bouillon 

Cheese  (American)  .  .  . 
Cottage  cheese  (curds)  .  . 
Neuch§,tel  (cream  cheese)  . 
Chicken  (broiler  E.  P.)  .  • 
Chicken  (broiler  E.  P.)  .  . 
Chocolate  (unsweetened) 

Cocoa 

Cocoa  

Condensed  milk  (Eagle 
brand)  (sweetened) 

Condensed  milk  (Eagle 
brand)  (sweetened) 

Condensed  milk  (unsweet- 
ened)    .... 

Consomm^    .     .     . 

Corn  (canned)    .     . 

Corn  (green  E.  P.) 

Cornmeal  (granular) 

Cornflakes^  (toasted) 

Cornstarch    .     .     . 

Crackers  (graham) 

Crackers  (water)    . 

Crackers  (oyster)  . 

Cracker  crumbs 

Cranberries   .     .     . 

Cream  18%  (single  X)     . 

Cream  40%  (double  XX) 

Cucumber,  E.  P.    .     .     . 

Currants  (dried)     .     .     . 


Weight 


1  OZ. 

lib. 


3oz. 

1  OZ. 

3oz. 
1  oz. 

1  OZ. 
1  OZ. 

6oz. 

1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 

3oz. 

1  OZ. 
1  OZ. 
J  OZ. 


1  OZ. 

i  OZ. 

i  OZ. 
6oz. 

1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 
i  OZ. 


1  OZ. 

!^  OZ. 

1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 


Measure 


2  tablespoonfuls 
2  cups  .     .     .     . 


1  medium 


1  serving 


1  stalk  medium  size     . 

2  tablespoonfuls      .     . 

1  cup 

2  tablespoonfuls,  grated 
2  tablespoonfuls      .     . 


1  serving 

1  square 

4  tablespoonfuls       .     . 

2  teaspoonfuls  (1  serv- 
ing)  


2  tablespoonfuls 
1  teaspoonful 


1  teaspoonful 

f  cupful     .     .     . 

2  tablespoonfuls 
2  tablespoonfuls 
2  tablespoonfuls 


3  tablespoonfuls 
1  cracker  .  .  . 
1  cracker  .     .     , 


2  tablespoonfuls 
2  tablespoonfuls 
2  tablespoonfuls 


2  tablespoonfuls 


Nitrogen 


.04 

.72 


.15 
.05 
.24 
.08 
.05 
.01 
.05 

1.31 
.95 
.85 
.97 

2.92 
.58 
.98 

.12 

.40 

.07 

.07 
1.06 
.13 
.14 
.42 
.25 

.15 
.19 
.51 
1.32 
.02 
.13 
.10 
.04 
.11 


'  Ontario  Department  of  Agriculture  Bulletin  162. 


METHODS  OF  FEEDING 


147 


XVIII  —  Continued 


Proteins 

Fats 

Carbohydrates 

Fuel 
Value 

% 

Gm. 

% 

Gm, 

% 

Gm. 

1.0 

.28 

85.1 

24.09 

217.3 

1.0 

4.53 

85.1 

385.5 

— 

— 

3488. 

1.1 

.93 

0.4 

.33 

9.3 

7.89 

38.2 

1.1 

.31 

0.4 

.11 

9.3 

2.63 

12.7 

1.8 

1.53 

0.5 

.42 

4.7 

3.99 

25.8 

1.8 

.51 

0.5 

.14 

4.7 

1.33 

8.6 

1.1 

.31 

0.1 

.03 

3.3 

.93 

5.2 

0.2 

.057 

— 

— 

0.2 

.057 

.45 

0.2 

.342 

— 

— 

0.2 

.342 

2.65 

28.8 

8.16 

35.9 

10.18 

0.3 

.09 

124.6 

20.9 

5.92 

1.0 

.283 

4.3 

1.21 

31.12 

18.7 

5.30 

27.5 

7.78 

1.5 

.42 

92.8 

21.5 

6.09 

2.5 

.708 

— 

— 

31.7 

21.5 

18.27 

2.5 

2.10 

— 

— 

92. 

12.9 

3.65 

46.7 

13.80 

30.3 

8.59 

173.3 

21.6 

6.12 

28.9 

8.19 

37.7 

10.69 

141. 

21.4 

.76 

28.7 

1.02 

37.5 

1.33 

17.5 

8.8 

2.49 

8.3 

2.35 

53.9 

15.34 

92.2 

11.6 

.41 

15.5 

.55 

72.0 

2.55 

12.3 

12.6 

.446 

12.4 

.441 

14.9 

.528 

7.84 

3.9 

6.63 

— 

0.4 

.68 

19.5 

2.8 

.79 

1.2 

.34 

19.0 

5.39 

27.8 

3.1 

.88 

1.1 

.31 

19.7 

5.38 

28.7 

9.3 

2.61 

1.9 

.54 

75.5 

21.38 

100.8 

5.5 

1.56 

1.5 

.43 

81.2 

23. 

102.1 

— 

— 

— 

— 

89.1 

25.52 

102. 

10.0 

.94 

9.3 

.88 

73.8 

6.97 

39.5 

12.7 

1.2 

0.5 

.05 

80.5 

7.6 

40. 

11.3 

3.20 

10.5 

2.98 

70.5 

19.98 

119.5 

11.6 

8.25 

6.3 

4.5 

77.7 

55.1 

294. 

0.4 

.11 

0.6 

.17 

10.0 

2.81 

13.2 

0.3 

.8 

19.7 

5.6 

4.9 

1.4 

59.2 

2.2 

.62 

40.0 

11.34 

3.0 

.85 

107.9 

0.8 

.23 

0.2 

.06 

3.1 

.88 

4.9 

2.4 

.68 

1.7 

.48 

74.2 

21.04 

91.2 

148 


DIETETICS  FOR  NURSES 


TABLE 


Material 


Dates  (dried) 
Dry  peptonoids 


E 
Eggs  (whole  without  shell) 

Egg  (white) 

Egg  (yolk) 

F 

Farina 

Figs  (dried) 

Flour  (barley)  .... 
Flour  (gum  gluten)  .  . 
Flour  (graham)  .... 
Flour  (wheat)  .... 
Flour  (wheat)  .... 
Flour  (entire  wheat)   .     . 

Fowl,  E.  P 

Fowl,  E.  P.    .     .     .     .     . 


G 
Gelatine  (granulated) 
Gelatine  (granulated) 
Gum  gluten  bread  .     . 
Gum  gluten  biscuit     . 
Greens,  A.  P.  (turnips) 
Greens,  A.  P.  (beet  tops) 
Greens,  cooked  .     .     . 
Grapes,  malaga .     .     . 


Grapes,  malaga 
Grape  juice   . 
Grape  juice   . 


H 

Halibut,  E.  P.  steak  .  .  . 
Ham  (lean),  smoked,  E.  P.  . 
Ham  (medium  smoked)  fat 

Hominy 

Hickory  nuts  (shelled)  .  . 
Honey 


Weight 


1  OZ. 
1  OZ. 


39.69 
grams 

T^OZ. 
§  OZ. 


1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 
i  OZ. 
1  OZ. 
1  OZ. 

3^  OZ. 


lib. 

1  OZ. 

4  OZ. 


3  OZ. 
L|  OZ. 

1  OZ. 
1  OZ. 
1  OZ. 
1  OZ. 


Measure 


2  tablespoonfuls 


1  medium  size 
1  white  .  . 
1  yolk  .     .     . 


tablespoonfuls 
fig  .  .  .  . 
tablespoonfuls 
tablespoonfuls 
tablespoonfuls 
tablespoonfuls 
tablespoonful  . 
tablespoonfuls 


1  serving 


1  tablespoonful 
1  slice   .     .     . 
1  biscuit    .     . 


1  serving 
Bunch 


2  tablespoonfuls 
^  cupful     .     .     . 


(about       12 


1  serving   .     .     . 
1  serving  (1  slice) 

1  slice   .... 

2  tablespoonfuls 
2  tablespoonfuls 


Nitrogen 


METHODS  OF  FEEDING 


149 


XVIII  —  Continued 


Proteins 

Fats 

Carbohydrates 

FuEIi 

Value 

% 

Gm. 

% 

Gm. 

% 

Gm. 

2.0 

.59 

2.8 

.79 

84.4 

22.2 

98.2 

21.1 

6. 

- 

~~~ 

28.2 

8. 

56. 

13.5 

5.35 

10.5 

4.16 

59.8 

12.2 

3.1 

0.2 

.054 

— 

— 

13. 

14.8 

2.1 

31.8 

4.5 

— 

— 

48. 

10.9 

3.11 

1.4 

.39 

76.4 

21.63 

102.6 

4.3 

1.21 

0.3 

.09 

74.1 

21. 

89.8 

10.2 

2.9 

2.2 

.62 

72.7 

20.6 

99.7 

36.3 

10.3 

1.3 

.36 

36.9 

10.44 

86.2 

13.3 

3.77 

2.2 

.62 

71.4 

20.24 

101.7 

11.2 

3.18 

1.0 

.28 

75.2 

21.24 

100.2 

11.2 

1.06 

1.0 

.09 

75.2 

7.08 

33.4 

13.8 

3.91 

1.9 

.53 

71.9 

20.38 

102. 

19.5 

5.51 

16.4 

4.65 

— 

— 

63.9 

19.5 

19.3 

16.5 

16.3 

— 

— 

224. 

91.5 

25.91 

0.1 

.028 

103.8 

91.2 

6.47 

0.1 

.007 

— 

— 

26.8 

29.7 

8.4 

1.1 

.30 

30.0 

8.5 

70.3 

41.9 

2.94 

1.8 

.13 

44.4 

3.15 

25.5 

4.1 

4.7 

0.6 

.68 

6.3 

7.1 

53.3 

2.1 

2.4 

3.3 

3.8 

3.2 

3.6 

58.2 

2.0 

2.3 

0.3 

.3 

3.2 

3.6 

26.3 

1.3 

.74 

1.6 

.9 

19.1 

10.88 

54.5 

1.3 

5.9 

1.6 

7.26 

19.2 

87.09 

437.3 

— 

— 

— 

— 

25.0 

7.09 

28.3 

— 

— 

— 

— 

25.0 

28.36 

113.4 

18.7 

15.81 

5.2 

4.41 

102.9 

19.8 

8.41 

21.0 

8.95 

— 

— ■ 

114.1 

16.3 

4.62 

38.8 

11. 

— 

— 

117.5 

8.3 

2.36 

0.6 

.17 

79.0 

22.39 

100.5 

15.4 

4.36 

67.1 

19. 

11.4 

3.22 

201.3 

0.4 

.11 

— 

— 

81.3 

23.02 

92.5 

150 


DIETETICS  FOR  NURSES 


TABLE 


Material 


Jell-0 
JeU-0 


Koumiss 
Koumiss 


Lactose  (sugar  of  milk) ;  IOC 
per  cent  carbohydrates 

Lady  fingers 

Lamb  chops  (broiled) 

Lard 

Lemon  juice  (1  lemon)    . 

Lemon  juice 

Lettuce 

Lettuce 

Liquid  peptonoids  .     .     . 

Lentils 

Lobster 


M 


Macaroni 

Mackerel  (fresh,  E.  P.) 
Mackerel,  salt  dressed,  E 
Malted  milk  (Horlick's) 
Milk  (whole)  .  .  . 
Milk  (whole)  .  .  . 
Milk  (skimmed)  .  . 
Molasses  (cane)  .  . 
Muskmelons  .... 


N 
Noodles  (gluten) 

O 

Oatmeal  .  .  . 
Oatmeal  (gruel) 
Oats  (rolled) 
Olives  .... 
Olive  oil  .  .  . 
Onion  .... 
Orange      .     .     . 


Weight 


3.5  oz. 
.6oz. 


lUtre 
4  oz. 


1  oz. 
h  oz. 
3  oz. 
1  oz. 
1^  oz. 

1  oz. 
8  oz. 

2  oz. 
1  oz. 

1  oz. 

2  oz. 


4  oz. 
3oz. 
2  oz. 
2  oz. 
1  oz. 
8  oz. 
1  oz. 
1  oz. 
8oz. 


2  oz. 


I  oz. 

4  oz. 
1  oz. 
^  oz. 

1  oz. 

2  oz. 

5  oz. 


Measure 


1  box    . 
1  serving 

1000  c.c. 
^  glassful 


tablespoonfuls 
lady  fingers     .     . 
chops,  medium  size 
tablespoonfuls 
tablespoonfuls 
tablespoonfuls 

head 

serving  (|  head)  . 
tablespoonfuls 
tablespoonfuls 
serving   .... 


cupful     .     .     . 
serving   .     .     . 
serving  (small) 
tablespoonful  . 
tablespoonfuls 
glassful  .     .     . 
tablespoonfuls 
tablespoonfuls 
small  melon     . 


f  cup 


1  tablespoonful 
^  cupful     .     . 


3  medium  size  . 
2  tablespoonfuls 
1  medium  size  . 
1  medium  size    . 


Nitrogen 


1.79 
.30 


4.01 
.51 


.20 
2.95 


.44 

.11 

.26 

1.17 

1.75 


2.43 

2.54 

1.57 

.37 

.15 

1.20 

.15 

.11 

.22 


2.05 


.38 
.21 
.76 
.02 

.07 
.14 


METHODS  OF  FEEDING 


151 


XVIII  —  Continued 


Proteins 

Fats 

Carbohydrates 

Fuel 
Value 

% 

Gm. 

% 

Gm. 

% 

Gm. 

11.3 

11.2 

87.3 

86.4 

395. 

11.2 

1.9 

— 

— 

84.7 

14.4 

66. 

2.8 

25.4 

2.1 

19.5 

5.4 

48.9 

473. 

2.8 

3.17 

2.1 

2.43 

5.4 

6.11 

58.9 

100.0 

28.35 

113.4 

8.7 

1.24 

4.9 

.70 

70.5 

10. 

51.2 

21.8 

18.45 

30.0 

25.44 

— 

— 

202.7 

— 

— 

100.0 

28.35 

— 

— 

255.2 

— 

— 

— 

— 

9.7 

4.12 

16.4 

— 

— 

— 

— 

9.8 

2.77 

11. 

1.2 

2.72 

0.3 

.72 

2.9 

6.50 

43.2 

1.2 

.68 

0.3 

.18 

2.0 

1.14 

10.8 

5.6 

1.6 

— 

— 

14.8 

4.2 

56. 

25.7 

7.29 

1.0 

.28 

59.2 

16.78 

98.8 

18.2 

10.34 

1.1 

.62 

0.5 

.28 

48.4 

13.4 

15.20 

0.9 

1.0 

74.0 

84. 

406. 

18.8 

15.90 

7.1 

6.03 

— 

— 

117.8 

17.3 

9.82 

26.3 

14.96 

— 

— 

173.9 

16.2 

2.3 

8.5 

1.2 

66.9 

9.5 

58. 

3.3 

.94 

4.0 

1.13 

5.0 

1.41 

19.6 

3.3 

7.52 

4.0 

9.04 

5.0 

11.28 

156.5 

3.4 

.96 

0.3 

.09 

5.1 

1.45 

10.4 

2.4 

.68 

— 

— 

69.4 

19.65 

81.3 

0.6 

1.36 

— 

— 

9.3 

21.12 

89.9 

22.5 

12.8 

2.1 

1.2 

16.3 

9.28 

99.3 

16.9 

2.4 

7.1 

1. 

65.9 

9.5 

56.9 

1.1 

1.3 

0.4 

.45 

0.6 

7.3 

38.4 

16.7 

4.73 

7.3 

2.07 

66.3 

18.77 

112.6 

10.6 

.15 

27.6 

3.91 

11.6 

1.64 

42.3 

— 

— 

aoo.o 

28.35 

— 

— 

255.1 

0.8 

.45 

0.2 

.09 

4.9 

2.80 

13.8 

0.6 

.85 

0.1 

.15 

8.6 

12.05 

53. 

152 


DIETETICS  FOR  NURSES 


TABLE 


Matebiazi 


Orange  (juice) 
Oysters     .     . 


Panopepton  .... 

Parsnips 

Peaches,  E.  P.  (fresh) 
Peaches,  canned     .     . 
Peanut  butter    .     .     . 
Peanuts,  shelled      .     . 
Pears,  fresh   .... 
Pears,  canned     .     .     . 
Peas,  green  (fresh,  E.  P.) 
Peas,  canned      .     .     . 
Peas  (dried,  split  peas) 
Pineapple  (canned) 
Pineapple  (fresh,  E.  P.) 
Pecans,  shelled  .     .     . 
Port  wine  (10%  alcohol) 
Potatoes  (white  raw)  . 
Potatoes  (sweet  raw)  . 
Prunes  (A.  P.)   .     .     . 
Prunes  (E.  P.)   .     .     . 


Quail 


Q 


R 


Raisins 

Raspberries  (black,  fresh)' 
Raspberries,  fresh,  juice  . 
Rhubarb,  fresh,  E.  P.      . 

Rhubarb 

Rice 


Rum 


Salmon  (canned)  . 
Salmon  (canned)  . 
Saltines  (crackers)  . 
Saltines  (crackers) . 
Sardines  (canned)  . 


Weight 


1  oz. 
1  oz. 


1  oz. 
1  oz. 
3  oz. 
3oz. 
1  oz. 


3oz. 

3  oz. 
3oz. 

4  oz. 
1  oz. 
3oz. 
3  oz. 
I  oz. 
h  oz. 


3oz. 
4  oz. 
1  oz. 
4  oz. 


3|oz. 


1  oz. 
1  oz. 
4  oz. 
1  oz. 
3oz. 
1  oz. 


1  oz. 


1  oz. 
1  lb. 
1  oz. 
1  ]b. 
1  oz. 


Measube 


2  tablespoonfuls 

3  small       .     .     , 


2  tablespoonfuls 
1  medium  size 
1  medium  size 

1  serving   .     . 

2  tablespoonfuls 


^  cupful     .     . 
1  medium  size 
1  serving   .     . 
1  serving,  about 
^  cup    .     .     . 
3  tablespoonfuls 
1  thick  slice   . 
1  serving   .     . 
^  cup     .     .     . 
1  tablespoonful 
1  medium  size 
1  medium  size 
3  A.  P.       .     . 
1  cupful     .     . 


cup 


I  quail,  1  serving 


3  dozen      .     .     . 
3  tablespoonfuls 


1  serving   .     .     . 

2  tablespoonfuls, 
serving  .     .     . 

2  tablespoonfuls 


1  can 


1  box    .... 

1  small  serving  . 


Nitrogen 


.28 


.32 

.10 

.10 

1.33 

3.32 

.08 

.04 

.95 

.65 

1.12 

.07 

.05 

.58 

.30 
.33 

.08 
.38 


1.00 


.12 

.08 

.03 
.08 

.36 


.99 

15.82 

.48 

7.68 

1.08 


METHODS  OF  FEEDING 


153 


XVlll  — Continued 


Proteins 

Fats 

Carbohydrates 

Fuel 
Value 

% 

Gm. 

% 

Gm. 

% 

Gm. 

11.3 

3.2 

12.8 

6.2 

1.75 

1.2 

.34 

7.4 

2.10 

18.4 

7.1 

2. 

_ 

_ 

17.3 

5. 

60. 

0.1 

.016 

— . 

.005 

0.5 

.135 

.65 

0.7 

.60 

0.1 

.09 

9.4 

8.01 

35.2 

0.7 

.60 

0.1 

.09 

10.8 

9.18 

39.9 

29.3 

8.31 

46.6 

13.20 

17.1 

4.85 

151.4 

29.3 

20.77 

46.5 

33. 

5.8 

4.12 

396.5 

0.6 

.51 

0.5 

.42 

14.2 

12. 

53.7 

0.3 

.27 

0.3 

.27 

18.1 

15.30 

64.5 

7.01 

5.94 

0.5 

.42 

15.9 

14.37 

84.9 

3.6 

4.08 

0.2 

.24 

9.8 

11.12 

62.8 

24.5 

6.97 

1.0 

.28 

62.0 

17.57 

100.7 

0.5 

.4 

0.7 

.6 

36.6 

31. 

130. 

0.4 

.33 

0.3 

.27 

9.7 

8.25 

36.6 

5.1 

3.60 

37.6 

26.7 

8.2 

5.80 

553. 
10. 
70.6 

2.2 

1.86 

0.2 

.09 

17.5 

15.66 

1.8 

2.04 

0.7 

.80 

27.4 

31.08 

139.6 

1.8 

.51 

— 

— 

62.2 

17.63 

72.5 

2.11 

2.40 

— 

— 

73.1 

83.12 

342. 

6.22 

6.22 

5.7 

5.7 

— 

— - 

113.3 

2.6 

.74 

3.3 

.94 

76.0 

21.57 

97.7 

1.7 

.48 

1.0 

.28 

12.6 

3.57 

18.8 

— 

— 

— 

— 

10.0 

11.3 

45.2 

0.6 

.17 

0.7 

.20 

3.6 

1.02 

6.6 

0.6 

.51 

0.7 

.60 

3.6 

3.06 

19.6 

7.9 

2.26 

0.3 

.09 

79.0 

22.39 

99.4 
76. 

21.8 

6.18 

12.1 

3.43 

55.6 

21.8 

98.87 

12.1 

54.88 

— 

— 

889. 

10.6 

3. 

12.7 

3.60 

68.5 

19.42 

122.1 

10.6 

48. 

12.7 

57.60 

68.5 

310.70 

1953.52 

23.7 

6.72 

12.1 

3.43 

— 

— 

57.7 

154 


DIETETICS  FOR  NURSES 


TABLE 


Material 


s 

Shad 

Shad  roe  .  .  .  . 
Sherry  wine  .  .  . 
Spinach     .     .     .     . 

Squab  

Squash  .  .  .  . 
Strawberries .  .  . 
Strawberry  juice  . 
Suet 

Sugar  (granulated) 
Sugar  loaf  .  .  . 
Sugar  (powdered)  . 
Sweetbreads  .  .  . 
Sweetbreads .     .     . 

T 
Tapioca    .     .     .     . 
Tapioca  (minute)   . 
Tomatoes  (fresh)    . 
Tomatoes  (canned) 

Trout  

Trout  

Turnips  (fresh)  .  . 
Turkey  .  .  .  . 
Turkey     .     .     .     . 

W 

Walnuts  .  .  .  . 
Walnuts  .  .  .  . 
Wheat  (shredded)  . 
Wheat  flakes  .  . 
Whey 

Z 

Zwieback  .     .     .     . 


Weight 


3oz. 
1  oz. 
1  oz. 
4  oz. 
J|  oz. 
3oz. 
3oz. 
4  oz. 
1  oz. 


1  oz. 
^  oz. 
i  oz. 
3oz. 
8oz. 


1  oz. 
1  oz. 
5  oz. 
1  oz. 
3oz. 
1  oz. 
3oz. 
2ioz. 
1  oz. 


1  oz. 
5|  oz. 
1  oz. 
1  oz. 
6  oz. 


1  oz. 


Measure 


1  serving 

1  small  serving   .     .     . 

2  tablespoonfuls      .     . 

^  cupful 

^  squab      

1  serving 

1  serving,  about  |  cupful 
i  cup 

2  tablespoonfuls 
packed  solid    .     .     . 

2  tablespoonfuls      .     . 

1  lump 

1  tablespoonful  .     .     . 

1  serving 

1  set 


2  tablespoonfuls 
2  tablespoonfuls 

1  whole  tomato  , 

2  tablespoonfuls 
1  serving   .     .     . 


Nitrogen 


1.96 
.95 

.38 

1.86 

.10 

.13 


1  serving   .     .     . 
1  serving  (2  slices) 


1  cupful 


1  cupful  (about) 
1  cupful     .     .     . 


3  small  slices . 


.21 


2.28 
6.08 


.02 
.02 
.07 
.05 

2.46 
.82 
.18 

2.39 
.96 


.84 

4.59 

.55 

.61 

.27 


.44 


METHODS  OF  FEEDING 


155 


XVIII  —  Continued 


Proteins 

Fats 

Carbohydrates 

Fuel 
Value 

% 

Gm, 

% 

Gm. 

% 

Gm. 

14.4 

12.24 

9.5 

8.07 

121.5 

20.9 

5.92 

34.2 

9.69 

2.6 

.73 

113.7 
28. 
27.2 

2~1 

2.36 

0.3 

.36 

3.2 

3.64 

16.4 

11.62 

36.4 

25.85 

— 

— 

279.1 

0.7 

.60 

0.2 

.18 

4.5 

3.84 

18.3 

1.0 

.84 

0.6 

.51 

7.4 

6.30 

33. 

— 

— 

— 

— 

4.8 

5.5 

22. 

4.7 

1.33 

81.9 

23.19 





214. 

— 

— 

— 

— 

100.0 

28.35 

113.40 

— 

— 

— 

— 

100.0 

7.1 

31.2 

— 

— 

— . 

— 

100.0 

9.45 

37.8 

20.5 

14.25 

13.2 

10.29 

— 

— 

149.61 

16.7 

38. 

12.1 

27.4 

— 

— 

398. 

0.4 

.11 

0.1 

.03 

88.1 

24.95 

100.5 

0.4 

.11 

0.1 

.03 

88.1 

24.95 

100.5 

0.3 

.42 

0.2 

.28 

2.1 

3.11 

16. 

1.2 

.34 

0.2 

.06 

3.8 

1.13 

6.4 

18.1 

15.4 

10.3 

8.76 

— 

— 

140.4 

18.1 

5.13 

10.3 

2.92 

— 

— 

46.8 

1.3 

1.11 

0.2 

.18 

8.1 

6.90 

33.6 

21.1 

14.94 

22.8 

16.22 

— 

— 

205.7 

21.1 

5.98 

22.6 

6.39 

— 

— 

81.4 

18.4 

5.22 

64.5 

18.26 

13.0 

3.69 

200. 

18.4 

28.71 

64.5 

100.43 

13.0 

20.39 

1099.6 

12.1 

3.43 

1.8 

.51 

75.2* 

21.31 

103.6 

13.4 

3.80 

1.4 

.39 

74.3 

21.06 

103. 

1.0 

1.70 

0.3 

.51 

4.4 

7.50 

41.3 

9.8 

2.77 

1.0 

2,80 

73.5 

20.83 

119.6 

SECTION  III 
NUTRITION  IN  DISEASE 


CHAPTER  IX 
PREGNANCY  AND  LACTATION 

There  are  many  traditions  in  regard  to  the  food  requirements 
of  the  prospective  mother.  Many  of  these  have  been  proved 
fallacies.  As  a  matter  of  fact  it  is  the  woman  more  than  the 
developing  child  who  is  likely  to  suffer  if  the  diet  is  insufficient  or 
badly  balanced. 

Factors  Affecting  Diet  during  Pregnancy.  —  In  formulating  a 
dietary  for  the  pregnant  woman,  then,  not  only  must  the  needs 
of  the  child  be  considered  but  those  of  the  mother  also,  since  the 
developing  embryo  draws  from  the  body  of  the  woman  materials 
necessary  for  its  growth,  and  if  these  needs  are  not  covered  by  an 
increase  in  the  diet,  her  body  and  that  of  the  child  also  will  show 
evidences  of  lack  of  nourishment. 

Phosphorus  and  Calcium  Requirements.  —  If,  for  example, 
the  mother's  diet  is  lacking  in  those  materials  which  produce 
growth,  or  is  deficient  in  those  mineral  salts,  such  as  phosphorus 
and  calcium,  which  are  requisite  and  necessary  for  the  growth  of 
bones  in  the  infant,  the  mother's  bones  and  teeth  will  show  this 
loss  and  in  all  probability  the  baby  will  sooner  or  later  also  show 
a  like  deficiency.  However,  it  must  be  remembered  that  the  preg- 
nant woman  is  under  a  strain,  both  physical  and  mental.  She 
must  not  be  encouraged  to  eat  beyond  her  needs  or  the  digestion 
will  be  disturbed. 

Nutritional  Disturbances  in  Early  Months.  —  The  nutritional 
disturbance  manifested  by  nausea  and  vomiting  in  the  morning  is 
due,  not  to  the  stomach  or  any  disturbance  therein,  but  to  the 
fact  that  a  mild  form  of  poisoning  occurs,  resulting  from  the  sub- 
stances produced  through  the  formation  of  the  placenta  reaching 
the  general  circulation  on  account  of  the  incomplete  establishment 
of  the  connection  between  the  embryo  and  the  mother.    As  soon 

159 


160  DIETETICS  FOR  NURSES 

as  this  connection  is  complete  and  fetal  circulation  is  established 
this  "  morning  sickness  "  disappears. 

Food  Requirements  of  Prospective  Mother.  —  The  food  re- 
quirements of  the  prospective  mother  are  not  materially  affected 
during  the  first  four  months  of  gestation,  and  even  after  this, 
when  the  infant  is  developing  rapidly,  and  up  to  the  date  of  its 
birth,  the  mother's  requirements  are  only  increased  about  20%. 
The  amount  of  food  necessary  to  cover  the  body  needs,  for  main- 
tenance and  energy  of  a  woman  living  a  sedentary  or  moderately 
active  life,  plus  20%  for  building  materials  for  the  growing  child, 
will  be  adequate  for  the  pregnant  woman.  Thus,  if  her  needs  are 
ordinarily  from  2000  to  2400  calories  per  day,  after  the  fourth 
month  they  will  probably  be  increased  to  2400  or  2800  calories 
a  day  and  will  rarely  ever  be  more  than  3000  calories  a  day. 

Dietetic  Treatment  of  Normal  Pregnancy.  —  The  peculiar  con- 
ditions surrounding  the  woman  at  this  particular  time  must  be 
taken  into  consideration  in  arranging  her  diet.  The  building  foods 
which  are  necessary  for  the  developing  child  must  be  given  in  the 
simplest  form,  milk  and  eggs  being  used  liberally  and  meat  spar- 
ingly to  obviate  any  unnecessary  tax  being  placed  upon  the  kid- 
neys. The  use  of  fruit  and  green  vegetables  to  supplement  the 
milk  and  eggs  is  urged.  It  has  been  found  advisable  at  such  times 
to  give  small  meals  frequently  rather  than  the  regular  meal  three 
times  a  day.  The  feeling  of  "  fullness  "  which  often  occurs  during 
the  last  two  or  three  months  of  gestation  makes  it  more  comfQrt- 
able  for  the  pregnant  woman  to  eat  less  at  a  time  and  oftener. 
If,  for  example,  she  be  given  a  glass  of  rich  milk  or  a  nutrient 
beverage,  either  of  enforced  malted  milk,  albumenized  orange 
juice,  buttermilk,  zoolak,  or  koumiss,  at  about  eleven  o'clock  in 
the  morning  and  again  about  four  o'clock  in  the  afternoon,  she 
will  have  taken  sufiicient  nourishment  to  meet  the  new  require- 
ments without  taxing  her  digestion  or  imposing  extra  work  upon 
the  kidneys. 

Abnormal  Symptoms.  —  The  chief  point  to  keep  in  mind  is  the 
abnormal  symptoms  which  may  develop.  The  chief  of  these  is 
albumen  in  the  urine.    The  urine  must  be  examined  frequently 


PREGNANCY  AND  LACTATION  161 

and  measures  taken  immediately  to  overcome  albuminuria  should 
it  occur.  It  is  wise,  as  has  already  been  stated,  to  restrict  the  meat 
in  the  diet,  and  in  cases  where  albumen  is  found  in  the  urine  even 
when  the  meats  are  restricted,  it  may  be  necessary  to  place  the 
patient  upon  a  milk  diet  for  a  time  until  the  urine  clears  up. 

Supplementary  Feeding.  —  Cereals,  especially  the  whole  cereals, 
must  be  used  liberally.  Gruels  made  with  milk  are  often  found 
valuable  additions  to  the  dietary.  The  prospective  mother  must 
be  urged  to  take  a  regular  amount  of  gentle  exercise,  not  to  be- 
come overtired,  or  excited,  to  eat  sparingly  at  night,  and  to  drink 
plenty  of  water.  She  must  avoid  becoming  constipated  by  eat- 
ing plenty  of  green  vegetables  and  fruit. 

Sample  Diet  Sheets.  —  The  following  dietary  is  suggested : 
Breakfast  should  consist  of  thoroughly  cooked  cereals,  wheatena, 
cream  of  wheat,  malt  breakfast  food,  cracked  wheat,  rolled  or 
cracked  oats,  served  with  cream  or  sugar  or  both,  whole  wheat 
bread,  muffins,  or  biscuits,  with  butter,  raw  or  stewed  fruit,  coffee, 
tea  or  cocoa  with  milk.  Luncheon  may  consist  of  milk  or  vege- 
table soups,  eggs  in  any  form,  boiled  potatoes,  sweet  potatoes, 
string  beans,  greens,  or  any  green  vegetables,  simple  desserts  such 
as  custards,  rice  or  tapioca  puddings,  bread  pudding,  etc.,  milk, 
tea,  cocoa,  buttermilk,  zoolak  or  koumiss  as  beverages.  For 
dinner,  if  albuminuria  is  not  present,  a  small  piece  of  meat  may 
be  taken,  together  with  green  vegetables,  rice,  potatoes,  simple 
salads,  and  a  simple  dessert,  milk  or  coffee  with  milk  as  a  beverage. 

Selection  of  Food.  —  The  following  foods  may  be  used  to  for- 
mulate the  diet  sheet :  Wheat,  oat,  or  corn  cereals,  rice,  tapioca, 
made  into  simple  puddings  or  served  as  breakfast  foods;  fruits, 
oranges,  prunes,  apples,  raisins,  dates,  figs,  or  grapefruit,  stewed  or 
raw.  The  fruit  juices  may  be  used  instead  of  the  whole  fruit  if 
the  latter  disagrees.  Vegetables :  peas  (green  or  dried),  beans 
(string  beans  or  dried  beans),  spinach,  greens  (turnip,  mustard,  or 
beet),  cabbage,  onions,  celery,  lettuce,  served  as  vegetables  or  in 
soups,  potatoes.  Meat:  lightly  broiled  beefsteak  or  stewed  or 
boiled  meat  or  chicken  served  not  more  than  once  a  day  or  three 
tiines  a  week.     Eggs,  prepared  in  different  ways.     Cheese  dishes. 


162  DIETETICS  FOR  NURSES 

Breakfast  bacon  or  ham  in  moderate  quantities,  butter,  olive  oil 
(or  other  salad  oils)  in  moderation,  whole  wheat,  graham  or  bran 
bread,  Boston  brown  bread  and  crackers,  milk,  cocoa,  chocolate, 
buttermilk,  malted  milk,  koumiss,  or  zoolak ;  coffee  and  tea  in 
moderation. 

The  diet,  as  has  already  been  stated,  may  be  supplemented  by 
nutrient  beverages  or  milk  gruels. 

DIET  IN  LACTATION 

The  diet  of  the  nursing  mother,  as  has  been  explained  in  a  pre- 
vious chapter,  must  not  only  cover  her  own  requirements  but  must 
likewise  be  adequate  to  furnish  the  extra  requirements  imposed  by 
the  nursing  infant. 

Food  Requirements  of  Nursing  Infant.  —  When  the  baby  is  a 
month  old  he  should  be  growing  rapidly,  and  his  food  require- 
ments at  this  period  and  until  he  is  about  three  months  old  will 
be  approximately  fifty  calories  per  pound  of  body  weight  in  the 
twenty-four  hours.  As  he  grows  older  his  requirements  grow 
gradually  less  in  proportion  to  his  weight.  This  is  because  the 
rate  of  growth  is  less,  so  that  for  the  next  three  months  the  require- 
ments are  from  43  to  40  calories  per  pound  of  body  weight  per 
day,  and  35  calories  per  pound  during  the  last  three  months,  or 
by  the  end  of  the  first  year  of  life. 

It  has  been  estimated,  as  before  stated,  that  the  average  infant 
will  take  2^  to  2^  ounces  of  mother's  milk  per  day  ^  to  each  pound 
of  body  weight  and  that  every  ounce  of  mother's  milk  will  yield 
on  an  average  20  calories.  Hence  a  month-old  baby  weighing 
ten  pounds  will  be  taking  about  23  ounces  a  day,  yielding  460 
calories.  Scientists  have  estimated  that  for  every  calorie  pro- 
duced by  the  milk  two  extra  calories  must  be  provided  by  food, 
so  that  for  the  baby  requiring  460  calories  per  day,  to  cover  his 
requirements  the  mother  will  be  obliged  to  consume  extra  food 
to  yield  920  calories,  or  the  regular  amount  to  meet  her  normal 
requirements  plus  the  extra  food  to  make  sufficient  food  for  the 
baby. 

1  "Feeding  the  Family,"  p.  93,  by  Mary  Swartz  Rose. 


PREGNANCY  AND  LACTATION  163 

Diet  of  Nursing  Mother.  —  The  diet  of  the  nursing  mother  need 
not  be  different  from  that  to  which  she  is  accustomed.  She 
should  be  warned  against  overwork  or  over-fatigue,  nervous  excite- 
ment and  worry,  since  these  factors  affect  the  digestion  of  the 
nursing  baby.  She  must  be  careful  not  to  eat  indigestible  foods 
or  foods  which  disagree  with  her,  as  such  things  will  undoubtedly 
affect  the  digestion  of  the  infant.  When  an  article  of  food  does 
cause  digestional  disturbances  in  the  baby,  it  should  be  carefully 
omitted  from  the  mother's  diet. 

Factors  Retarding  and  Stimulating  Milk  Secretion.  —  Consti- 
pation in  the  mother  reacts  quickly  and  unfavorably  upon  the 
secretion  of  milk.  The  same  has  proved  to  be  the  case  when 
she  becomes  excited,  nervous,  worried,  or  over-tired. 

The  average  diet  for  the  normal  woman  is  'safe  for  the  nursing 
mother.  If  her  supply  of  milk  is  deficient,  it  may  be  at  times 
increased  or  stimulated  by  the  drinking  of  a  glass  of  milk  between 
meals  or  by  taking  a  cup  of  hot  cereal  milk  gruel.  It  was  formerly 
believed  that  beer,  ale,  or  stout  acted  directly  upon  the  mammary 
glands,  stimulating  the  secretion  of  milk,  but  there  is  little  proof 
of  this  and  the  drinking  of  alcoholic  beverages  need  not  be  en- 
couraged on  this  account,  since  often  more  nourishing  beverages 
fulfill  the  purpose  more  efficiently  and  without  bad  results. 

SUMMARY 

Gastric  Disturbances.  —  The  nausea  and  vomiting  so  often  a 
part  of  early  pregnancy  is  not  believed  to  be  the  result  of  a  dis- 
ordered stomach  but  primarily  a  mild  form  of  poisoning  resulting 
from  the  incomplete  establishment  of  the  fetal  circulation. 

Adjusting  the  Diet.  —  The  adjustment  of  the  diet  to  cover  the 
needs  of  the  prospective  mother  and  those  of  the  developing  child 
is  essential.  The  amount  of  food  taken  by  the  mother  is  not 
materially  changed  during  the  first  three  months  of  gestation. 
An  average  normal  diet  is  all  that  is  necessary.  After  this  time  a 
twenty  per  cent  increase  in  the  woman's  diet  will  furnish  adequate 
means  both  for  her  maintenance  and  for  the  growth  and  develop- 
ment of  the  child. 


164  DIETETICS  FOR  NURSES 

T5rpe  of  Food.  —  The  kind  of  food  which  is  necessary  for  the 
pregnant  woman  to  take  during  this  period  is  very  similar  to  that 
taken  ordinarily.  It  is  necessary  to  furnish  food  materials  rich 
in  calcium  and  phosphorus,  with  an  adequate  supply  of  proteins 
in  their  simplest  form  in  order  to  meet  the  requirements  of  the 
growing  organism.  Milk  and  eggs  furnish  the  most  efficient  foods 
in  this  respect  and  the  prospective  mother  should  see  that  they 
form  the  chief  items  of  her  daily  dietary.  Milk  furnishes  calcium 
in  its  most  available  form  for  the  developing  skeleton  of  the  grow- 
ing infant,  hence  it  is  necessary  to  provide  the  mother  with  food 
to  replace  the  mineral  which  is  withdrawn  from  her  body. 

Meat  in  the  Diet.  —  Meat  should  be  eaten  sparingly  by  the 
prospective  mother,  as  it  imposes  needless  work  upon  the  already 
taxed  kidneys  and,  if  eaten  in  excess,  will  give  rise  to  dangerous 
complications.  Milk  and  eggs  will  provide  ample  protein  for  all 
purposes. 

Albumen  in  the  Urine.  —  Albuminuria  is  one  of  the  most  fre- 
quent complications  in  pregnant  women.  It  should  be  combated 
and  controlled  as  soon  as  possible.  The  allowance  of  meat 
should  be  cut  down  or  entirely  eliminated  from  the  diet  until  the 
urine  clears  up.  When  albuminuria  is  persistent  in  spite  of  ef- 
forts to  overcome  it,  the  patient  must  be  placed  upon  a  strict 
milk  diet  as  used  in  acute  nephritis,  to  prevent  dangerous 
complications  arising. 

LACTATION 

Diet  of  Mother.  —  Her  dietary  need  not  differ  materially  from 
that  to  which  she  is  accustomed.  She  must  avoid  indigestible 
foods  or  any  article  which  has  been  proved  to  disagree  with 
either  the  infant  or  herself. 

Factors  Regarding  Secretion  of  Milk.  —  Constipation,  worry, 
nervous  excitement,  and  over-fatigue  all  have  an  unfavorable 
effect  upon  the  secretion  of  milk  and  must  therefore  be  avoided 
by  the  nursing  mother. 

The  Bowels.  —  Constipation  of  the  mother  reacts  quickly  and 
unfavorably  upon  the  health  and  comfort  of  the  baby,  hence  it 


PREGNANCY  AND  LACTATION  165 

should  be  avoided  by  eating  coarse  breads,  green  vegetables,  and 
fruits,  when  they  do  not  disagree  with  the  baby,  by  drinking  plenty 
of  water  and  taking  a  certain  amount  of  outdoor  exercise  to  keep 
her  own  health  in  good  condition. 

Stimulating  the  Milk  Production.  —  When  the  milk  supply  is 
deficient  it  will  be  advisable  for  the  mother  to  drink  a  glass  of 
milk  or  a  bowl  of  cereal  milk  gruel  between  meals.  Alcoholic 
beverages  are  not  necessary  to  insure  an  adequate  secretion  of 
milk.  The  milk  or  milk  gruels  answer  the  purpose  more  efficiently 
and  without  bad  results. 

Energy  Requirements  of  Infant.  —  The  average  baby  requires 
fifty  calories  per  day  per  pound  of  body  weight  to  cover  his  energy 
growth  and  development  needs  for  the  first  three  months  of  life, 
after  which  the  rate  of  growth  is  less  and  his  requirements  decrease 
from  forty-three  to  forty,  then  to  thirty-five  calories  per  day  per 
pound  by  the  end  of  his  first  year. 

Amoimt  of  Milk  Needed  for  Infant.  —  Approximately  two  and 
one-third  ounces  to  each  pound  of  body  weight  per  day  covers  the 
needs  of  the  average  baby. 

Fuel  Value  of  Mother's  Milk.  —  Each  ounce  of  milk  yields 
twenty  calories. 

The  Making  of  Milk.  —  It  has  been  estimated  that  for  every 
calorie  yielded  by  milk,  two  extra  calories  must  be  provided  by 
food. 


CHAPTER  X 
INFANT  FEEDING 

In  taking  up  this  part  of  our  study  on  nutrition,  there  are  several 
points  to  be  kept  in  mind  by  the  nurse :  (1)  that  it  will  be  diflS- 
cult,  if  not  impossible,  to  understand  the  metabolic  changes  tak- 
ing place  in  abnormal  conditions  unless  those  occurring  in  the 
normal  human  body  are  understood ;  (2)  that  certain  diseases  are 
due  directly  to  errors  in  diet ;  (3)  that  in  other  diseases,  diet  plays 
the  chief  part  both  in  the  bringing  about  and  in  the  relieving  of 
the  conditions;  (4)  whereas  there  are  certain  other  diseases  not 
affected  by  diet,  save  in  so  far  as  well  or  poorly  selected  and  pre- 
pared food  always  affects  the  individual,  whether  normal  or  ab- 
normal, and  that  in  the  latter  conditions  the  organism  is  more 
susceptible  to  bad  influences. 

This  being  the  case  it  behooves  the  nurse  to  examine  herself  to 
find  whether  or  not  she  understands  the  fundamental  principles 
underlying  the  nutrition  of  the  human  body,  that  she  may  effi- 
ciently deal  with  the  changes  which  occur  more  or  less  when  the 
body  is  attacked  by  disease. 

We  include  normal  infant  feeding  in  this  section,  because  in  no 
other  age  is  it  quite  so  necessary  for  care  to  be  observed  in  formu- 
lating and  carrying  out  a  diet.  Errors  during  this  period  may 
only  appear  to  exert  a  local  influence,  causing  disturbance  which 
may  readily  be  relieved,  but  the  danger  is  in  laying  too  little  stress 
upon  these  disturbances,  forgetting  that  the  delicate  organism  of 
a  child  may  be  permanently  injured  by  a  constant  disregard  of 
nature's  mandates.  In  the  words  of  the  old  adage,  the  pitcher 
may  go  once  too  often  to  the  well,  and  an  injured  digestive  appara- 
tus is  even  more  difficult  to  mend  than  the  proverbial  pitcher. 

In  this  section,  then,  the  metabolic  changes  due  to  pathological 
conditions  and  the  dietetic  treatment  thereof  will  be  discussed. 

166 


INFANT  FEEDING  167 

The  formulas  suitable  for  the  various  conditions  are  to  be  found 
at  the  end  of  this  section. 

NORMAL  INFANT  FEEDING 

Much  has  been  written  in  the  past  few  years  on  the  care  and 
feeding  of  infants  and  children.  This  is  well,  since  statistics  show 
an  alarming  increase  in  the  rate  of  infant  mortality  during  the  early 
years  of  life,  and  anything  which  can  be  done  to  check  this  lamen- 
table and  often  avoidable  waste  of  valuable  life  should  be  resorted 
to  with  care  and  attention. 

Food  for  Infants.  —  The  natural  food  of  all  young  mammals  is 
the  milk  of  their  own  mother.  The  rate  of  growth  and  develop- 
ment differs  in  every  species;  the  calf,  for  example,  doubles 
birth  weight  much  more  quickly  than  does  the  baby  of  the  same 
age.  However,  the  milk  of  the  cow,  which  meets  the  needs  of  the 
calf  perfectly,  falls  short  of  meeting  the  requirements  of  the  in- 
fant, whose  rate  of  growth  is  not  nearly  so  rapid.  For  this  reason 
if  for  no  other,  it  would  be  advisable  to  give  the  baby  its  natural 
food  rather  than  to  attempt  a  substitute  which  is,  at  best,  a  poor 
one. 

Weight.  —  The  average  infant  weighs  from  six  to  seven  pounds 
at  birth.  This  weight  should  be  doubled  in  the  first  five  or  six 
months  of  life  and  tripled  by  the  end  of  the  first  year.  The  most 
important  business,  then,  in  the  life  of  the  child  during  the  early 
years  is  growth  and  development.  To  achieve  this  properly  the 
baby's  habits  must  be  adjusted  to  his  needs. 

Regularity  in  Feeding.  —  He  must  have  the  proper  food  and 
enough  of  it,  and  have  it  given  at  regular  intervals,  "  by  the 
clock,"  for  guesswork  is  fatal  in  infant  feeding.  He  must  be 
given  water  between  meals.  Babies  often  cry  from  thirst  when 
they  are  thought  to  be  doing  so  from  hunger  or  temper,  or  both. 
The  healthy  baby  sleeps  about  twenty-two  hours  out  of  twenty- 
four  during  the  early  months,  and  even  during  the  latter  six  months 
of  the  first  year  more  time  is  spent  in  sleeping  than  in  waking. 

The  Bowels.  —  The  bowels  should  move  several  times  a  day, 
the  stools  being  smooth  and  of  a  yellowish  color,  of  the  consistency 


168  DIETETICS  FOR  NURSES 

of  pea  soup.  After  the  first  month,  twice  a  day  is  about  the 
normal  number  of  stools  for  the  healthy  baby.  The  infant  should 
be  placed  upon  a  vessel  held  in  the  lap  of  the  nurse  at  regular 
times,  preferably  right  before  the  morning  bath,  and  in  the  eve- 
ning. In  this  way  regularity  in  evacuating  the  bowels  is  obtained, 
and  a  habit  formed  which  will  prove  valuable  through  life. 

The  Bath.  —  The  daily  bath  is  likewise  necessary  for  the  health 
and  comfort  of  all  babies,  as  is  fresh  air  and  sunshine. 

As  has  already  been  stated,  breast  milk  is  much  better  for 
babies  than  cow's  milk  or  any  artificial  food.  There  is  something 
in  the  mother's  milk  which  gives  strength  and  resistance  to  the 
baby  which  is  absolutely  lacking  in  any  other  food  no  matter  how 
carefully  it  is  selected  and  prepared,  and  for  this  reason  young 
mothers  must  be  prevailed  upon  to  nurse  their  babies  whenever 
it  is  possible  for  them  to  do  so.  When  circumstances,  such  as 
having  to  be  away  all  day  at  work,  make  it  impossible  for  a  mother 
to  nurse  her  baby  at  regular  intervals,  she  can  be  taught  how 
necessary  are  two  or  three  breast  feedings  a  day  to  the  future 
welfare  of  her  child.  When  social  reasons  or  lack  of  desire  on  the 
part  of  the  mother  make  her  unwilling  to  nurse  her  baby,  it  is 
the  part  of  the  nurse  to  lay  the  case  before  her  and  let  her  judge 
whether  or  not  she  is  willing  to  accept  the  responsibility  of  bring- 
ing into  the  world  a  life  for  which  she  is  unwilling  to  provide 
weapons  with  which  to  fight  the  good  fight. 

Habits  of  Mother.  —  The  mother  must  be  taught  how  to  effi- 
ciently nurse  her  baby ;  she  must  keep  in  mind  that  upon  her  good 
health  and  temperate  habits  depend  the  health  and  comfort  of 
her  baby.  It  devolves  upon  her  to  provide  food  efficient  in  quality 
and  quantity.  To  do  this,  her  own  diet  must  be  simple  and  whole- 
some. The  nursing  mother  must  remember  that  she  has  to  pro- 
vide, not  only  for  her  own  maintenance  and  energy  requirements, 
but  also  for  the  infant  whose  fuel  requirements  are  ever  demand- 
ing more  food  to  provide  for  its  rapid  growth. 

Food  and  Its  Relation  to  Milk.  —  It  is  believed  that  two  calories 
of  food  extra  are  necessary  to  produce  one  calorie  of  milk,  and  since 
a  month-old  baby  requires  2^  ounces  of  mother's  milk  to  every 


INFANT  FEEDING  169 

pound  of  his  body  weight,  and  one  ounce  of  mother's  milk  will 
yield  20  calories,  it  is  clearly  seen  that  the  mother  would  have  to 
increase  her  diet  to  cover  the  requirements  of  the  baby.  For 
example,  if  the  baby  weighed  12  pounds,  he  would  require  28 
ounces  of  milk  in  24  hours,  or  560  calories.  Thus  if  it  requires 
two  calories  of  extra  food  to  make  one  calorie  of  milk,  the 
mother's  diet  would  have  to  provide  1120  calories  extra,  or 
about  as  much  food  as  would  fulfill  the  needs  of  a  laboring  man, 
3000  to  3500  calories,  even  if  she  were  doing  practically  no  actual 
work;  while  if  she  were  actively  employed  and  doing  a  certain 
amount  of  physical  labor,  her  rations  would  have  to  approximate 
those  of  a  man  doing  heavy  muscular  work  (about  3500  to  4000 
calories  per  day).^ 

Breast  Milk  versus  Cow's  Milk.  —  Consensus  of  opinion  shows 
that  breast-fed  infants  require  less  energy  than  the  ones  who  must 
be  nourished  artificially.  This  is  probably  due  largely  to  the  fact 
that  the  constituents  of  human  milk  are  in  a  more  available  form 
than  those  in  cow's  milk,  the  former  requiring  a  lesser  expenditure 
of  energy  on  the  part  of  the  organism  to  become  available  than 
the  latter.  Very  active  babies,  ones  who  kick  and  throw  them- 
selves about  or  cry  violently,  have  a  greater  energy  requirement 
than  the  more  placid  baby  who  sleeps  more  and  is  more  quiet  in 
movement  and  who  cries  less  when  awake.  Breast-fed  babies  are 
generally  more  quiet  than  their  less  fortunate  artificially  fed 
brothers.  It  has  been  demonstrated  that  the  artificially  fed  baby 
has  a  much  harder  fight  for  existence  than  the  baby  who  receives 
his  natural  food ;  hence  the  necessity  of  using  every  available 
means  to  make  the  food  digestible,  and  to  lessen  the  danger  aris- 
ing from  the  additional  work  put  upon  the  entire  apparatus. 
Cow's  milk  contains  practically  the  same  chemical  elements  as  are 
found  in  human  milk,  but  these  elements  are  combined  in  a 
slightly  different  manner,  and  are  not  so  easily  handled  by  the 
immature  organs  The  proteins  of  milk  consist  of  casein,  which 
is  insoluble,  and  albumen,  which  is  soluble.  According  to  Van 
Slyke  the  proportion  of  insoluble  to  soluble  protein  in  cow's  milk 

1  "Feeding  the  Family,"  by  Mary  Swartz  Rose. 


170 


DIETETICS  FOR  NURSES 


is  3.6  :  1,  while  in  human  milk  the  proportion  is  only  1:1.  The 
ash  constituents  in  cow's  milk  are  in  excess  of  the  needs  of  the 
infant  organism,  but  since  a  great  part  of  these  salts  is  in  an  in- 
organic form  they  are  not  retained  to  the  same  extent  as  those 
contained  in  human  milk,  which  are  in  an  organic  form. 

Rules  and  Regulations.  —  It  is  not  possible  to  lay  down  hard 
and  fast  laws  to  cover  the  subject  of  infant  feeding.  The  food 
must  be  adapted  to  the  individual  needs  of  the  baby  in  question. 
The  nurse  must  see  that  the  milk  is  obtained  from  a  responsible 
dealer,  certified  milk  being  of  course  the  safest.  The  bottles  of 
milk  should  be  wiped  off  carefully  and  placed  directly  on  the  ice 
as  soon  as  they  are  received.  The  milk  generally  used  in  infant 
feeding  has  a  fat  content  of  4  per  cent.  That  having  a  higher 
percentage  of  fat  is  technically  cream.  The  following  table  show- 
ing the  fat,  sugar,  and  protein  composition  of  whole  milk,  cream, 
skimmed  milk,  and  whey  was  arranged  by  Morse  and  Talbot :  ^ 

TABLE  XIX 


Fat 

Milk  Sugar 

Protein 

Whole  milk 

7%  cream. 

10%  cream 

16%  cream 

32%  cream 

Skimmed  milk 

Separated  milk  (fat  free)    . 
Whey 

4.00 

7.00 

10.00 

16.00 

32.00 

1.00 

0.25 

0.25 

4.50 
4.45 
4.40 
4.20 
3.40 
5.00 
5.00 
5.00 

3.50 
3.40 
2.25 
3.05 
2.50 
3.55 
3.65 
0.90 

Seven  per  cent  (7  %)  cream  is  obtained  from  the  upper  16  ounces 
of  a  quart  bottle  of  milk  which  has  been  allowed  to  stand  undis- 
turbed for  six  hours.  The  upper  third  of  the  bottle  contains  10  % 
fat,  while  the  whole  fat  layer  from  the  quart  bottle,  regardless  of 
the  number  of  ounces,  contains  about  16%  of  fat. 

The  following  table  by  Sherman  gives  the  composition  of  the 
whole  bottle  of  milk  with  the  ratio  of  fat  to  protein. 

'"Diseases  of  Nutrition  and  Infant  Feeding,"  p.  218,  by  Morse  and  Talbot. 


INFANT  FEEDING 


171 


TABLE   XX  5 

Average  Composition  of  Top  Milk  After  Standing  from  12  to  24 
Hours  in  a  Quart  Bottle 


Fat 

Protein 

Sugar 

Ratio  of  Fat 

Per  Cent 

Per  Cent 

Per  Cent 

to  Protein 

Upper    1  oz.      ... 

22.5 

2.8 

4.0 

8.0:1 

Upper    2  oz. 

21.5 

2.8 

4.0 

7.7:1 

Upper    4  oz. 

20.0 

2.8 

4.0 

7.1:1 

Upper    6  oz. 

17.0 

2.9 

4.2 

5.9:1 

Upper    8  oz. 

14.0 

3.0 

4.3 

4.7:1 

Upper  10  oz. 

11.5 

3.0 

4.3 

3.8:1 

Upper  12  oz. 

9.8 

3.1 

4.5 

3.2 : 1 

Upper  16  oz. 

7.6 

3.1 

4.6 

2.5:1 

Upper  20  oz. 

6.2 

3.2 

4.7 

1.9:1 

Upper  24  oz. 

5.2 

2.2 

4.8 

1.6:1 

Upper  28  oz. 

4.5 

3.3 

4.8 

1.4:1 

Whole  quart 

4.0 

3.3 

4.8 

1.21:1 

To  utilize  the  above  table  it  is  only  necessary  to  select  the  milk 
from  the  column  containing  the  desired  ratio  of  fat  to  protein. 
Suppose  a  baby  requires  a  formula  containing  2  per  cent  protein, 
3.1  per  cent  fat,  and  7  per  cent  sugar,  to  be  given  in  eight  feedings 
of  3  ounces  each ;  as  whole  milk  has  a  ratio  of  3.1  to  2  or  1.6  to  1.0, 
it  is  obvious  that  a  milk  containing  a  higher  percentage  of  fat 
must  be  selected.  This  is  done  by  selecting  milk  from  the  upper 
ounces  rather  than  from  the  whole  quart.  In  the  upper  24  ounces 
the  ratio  of  fat  to  protein  is  correct,  but  the  composition  shows 
that  there  is  1.67  more  fat  than  is  needed;  consequently  the  24 
ounces  will  have  to  be  diluted  1.67  times  or  24  X  1.67,  which  will 
bring  the  quantity  up  to  40  ounces,  showing  that  16  ounces  of 
water  or  other  diluent  have  been  used  in  order  to  make  the  24 
ounces  of  milk  available  for  the  formula.  If  the  fat,  protein,  and 
sugar  percentages  in  the  undiluted  24  ounces  of  milk  are  divided 
by  1.67,  the  composition  of  the  diluted  milk  will  be  seen  to  be 
protein  1.9  per  cent,  fat  3.1  per  cent,  and  sugar  2.87  per  cent. 
After  thus  adjusting  the  fat  and  protein,  the  sugar  remains  to  be 

•  From  "Laboratory  Handbook  of  Dietetics,"  by  Mary  Swartz  Rose. 


172  DIETETICS  FOR  NURSES 

adjusted,  and  since  the  formula  calls  for  7  per  cent  sugar,  the  reduc- 
tion of  that  constituent  to  2.87  per  cent  is  clearly  too  much.  This 
is  remedied  by  adding  the  difference,  which  would  be  7— 2.87  %  = 
4.13  per  cent;  —  4.13  per  cent  of  40  ounces  equals  1.65  ounces  of 
milk  sugar  or  dextri-maltose  which  must  be  added.  Other  for- 
mulas can  be  figured  out  in  a  like  manner. 

Methods  of  Artificial  Feeding.  — The  use  of  whole  milk,  top  milk, 
or  skimmed  milk,  diluted  with  water,  and  either  milk  sugar,  malt 
sugar,  or  sucrose  (cane  sugar)  added,  is  the  method  of  feeding  most 
commonly  used,  and  upon  it  are  based  the  formulas  universally 
advised  by  infant  specialists.  There  are  cases  in  which  simple 
dilution  is  not  advisable.  In  premature  or  very  young  infants, 
for  example,  the  whey  mixtures  have  been  found  to  give  the  best 
results.  In  toxic  diarrheas,  where  the  putrefactive  bacteria  make 
the  use  of  all  but  the  minimum  amount  of  protein  inadvisable,  the 
above  method  is  contraindicated,  as  it  is  likewise  in  cases  where 
vomiting  of  casein  curd  is  a  protiainent  feature."* 

The  Use  of  Alkalies.  —  There  are  many  cases  in  which  the  phy- 
sician deems  it  advisable  to  add  an  alkali  to  the  milk  mixture. 
The  one  generally  selected  is  limewater.  However,  sodium  citrate 
and  sodium  bicarbonate  are  also  used.  The  reasons  for  adding 
alkalies  to  the  milk  mixtures  are :  (1)  to  check  the  coagulation  of 
the  casein,  (2)  to  hasten  the  emptying  of  the  stomach,  or  (3)  to 
chemically  change  the  formation  of  the  curd.  In  certain  cases  it 
is  only  necessary  to  delay  the  coagulation  of  the  casein  in  the 
stomach,  in  which  case  a  certain  amount  of  limewater  is  used. 
Its  action  is  to  swell  the  protein  of  the  milk  and  in  this  way  effect 
the  precipitation  of  the  casein.  In  other  cases  it  is  found  advis- 
able to  prevent  the  formation  of  curd  and  hasten  its  departure 
from  the  stomach.  Cannon  ^  claims  that  milk  before  it  coagulates 
leaves  the  stomach  quickly  like  water  in  gushes.  Hence,  if  an  alkali 
like  limewater,  bicarbonate  or  citrate  of  soda  is  added  to  the  milk 
this  coagulation  will  be  checked  and  the  digestion  be  facilitated. 

*  "Generally  Accepted  Methods  for  Artificial  Feeding  of  Infants  with  Indicatives 
and  Contra-Indicatives, "  by  Orville  R.  Chadwell,  M.D.  Reprinted  from  "New 
England  Medical  Gazette,"  June,  1916. 

6  "Mechanical  Factors  of  Digestion,"  by  Cannon. 


INFANT  FEEDING  173 

Amount  and  Type  of  Alkali  Used.  —  The  amount  of  alkali  ^ 
necessary/  to  bring  about  any  change  in  the  general  effect  of  the 
formula  must  be  determined  by  the  amount  of  milk  and  cream  in 
the  mixture,  since  these  constituents  alone  determine  the  acid 
content.  However,  it  is  impossible  to  judge  exactly  the  amount  of 
alkali  to  add,  but  an  approximate  estimate  is  made  from  the  work 
done  by  the  various  investigators.  It  has  been  estimated  that 
from  25  to  50  per  cent  of  limewater  must  be  added  to  milk  to 
change  it  to  any  marked  degree.  In  using  bicarbonate  of  soda,  a 
much  less  quantity  brings  about  the  desired  result,  1^  grains  of 
bicarbonate  of  soda  being  equal  to  one  ounce  of  limewater.  The 
action  of  these  two  alkalies  is  different.  The  soda  acting  upon 
the  milk  causes  the  curds  to  be  more  porous,  and  therefore 
more  easily  acted  upon  in  digestion. 

Sodium  citrate  likewise  tends  to  prevent  the  formation  of  tough 
curds.  It  is  added  in  amounts  of  1  to  2  grains  to  each  ounce  of 
milk  or  cream  in  the  mixture  whenever  it  is  found  necessary  to 
use  it  at  all. 

The  addition  of  any  alkali  to  the  formula  is  resorted  to  if  the 
symptoms  indicate  the  need  for  it,  but  the  type  and  quantity  is 
entirely  within  the  province  of  the  physician,  not  the  nurse. 

The  Addition  of  Sugar.  —  Lactose  is  the  form  in  which  the  car- 
bohydrates are  found  in  all  milk,  and' it  has  been  a  general  rule  to 
employ  this  sugar  in  making  up  the  sugar  content  of  a  formula, 
using  from  6  to  7  per  cent  of  the  mixture  in  this  form  to  cover  the 
necessary  energy  requirements  of  the  infant.  Other  sugars  are 
used,  however;  and  of  late  years  malt  sugar  has  been  widely 
employed  for  this  purpose.  The  form  now  generally  accepted  is 
known  as  dextri-maltose,  which  is  a  combination  of  dextrin  and 
maltose,  both  of  which  are  readily  acted  upon  by  the  sugar-splitting 
enzymes  of  the  digestive  juices.  In  digestion,  lactose  or  milk 
sugar  is  split  to  dextrose  and  galactose  and  utilized  in  the  body, 
both  as  a  source  of  energy  and  as  a  food  for  the  lactic  acid  bacteria 
which  are  active  in  the  small  intestine. 

Malted  Foods.  —  The  addition  of  malted  foods  or  malt  sugar 

«" Diseases  of  Nutrition  and  Infant  Feeding,"  p.  204,  by  Morse  and  Talbot. 


174  DIETETICS  FOR  NURSES 

to  the  food  of  infants  tends  to  bring  about  a  more  rapid  gain,  both 
in  energy  and  in  body  weight,  than  is  generally  the  case  where 
other  sugars  are  used.  This  sugar  is  used  as  a  substitute  for  milk 
sugar  in  many  formulas,  especially  in  those  cases  in  which  the 
casein  of  cow's  milk  needs  to  be  made  more  digestible  in  form. 
Malt  sugar  is  indicated  in  the  following  conditions  ^ :  (1)  in  severe 
atrophies,  (2)  in  cases  of  fat  indigestion  before  the  atrophic  stage 
is  reached,  (3)  in  cases  where  there  is  slight  curd  indigestion, 
indicated  by  some  vomiting  and  slow  gain  in  weight,  (4)  in  cases 
where  excessive  intestinal  fermentation  is  manifested  by  gas  and 
colic. 

Malt  sugar  (dextri-maltose)  is  contraindicated  to  a  slight  degree 
in  cases  "  of  simple  acute  diarrhea  where  lactose,  by  supplying 
fermentative  media,  more  easily  restores  the  normal  bacterial 
balance." 

Cereal  Diluents.  —  Barley  and  oatmeal  water  are  used  as 
diluents  to  the  amount  of  one-fourth  or  more  of  the  mixture. 
Oatmeal  water  or  jelly  is  used  more  during  the  winter  months  than 
in  the  hot  summer  months.  As  the  fat  content  of  the  oatmeal 
gives  it  a  more  laxative  effect,  it  is  undesirable  to  use  it  at  the 
season  in  which  the  summer  diarrheas  are  prevalent.  Barley 
water  has  something  of  a  colloidal  action  upon  the  casein,  causing 
the  curds  to  be  finer  and  less  tough  in  character.  Both  barley 
and  oatmeal  water  are  used  in  place  of  plain  water  for  babies  when 
this  colloidal  effect  upon  the  curd  of  the  milk  is  desired,  also  where 
the  weight  of  the  infant  shows  a  disposition  to  remain  stationary, 
especially  where  there  are  no  other  symptoms  to  account  for  the 
lack  of  gain.  Whey  is  used  with  babies  who  cannot  digest  the 
insoluble  protein  of  cow's  milk.  This  is  often  the  case  in  pre- 
mature babies  and  is  manifested  by  a  persistent  vomiting  of  curd. 
The  energy  requirements  are  obtained  by  the  a4dition  of  cream 
and  lactose  to  the  whey. 

Buttermilk  Mixtures  and  "  Eiweissmilch."  —  It  is  often  found 
desirable  to  use  some  other  form  of  milk  than  whole,  top,  or  even 
skimmed  milk,  and  for  this  purpose  lactic  acid,  milk  and  the  albu- 

1  "New  England  Medical  Gazette,"  June,  1916.     Reprint  by  Orville  Chadwell. 


INFANT  FEEDING  175 

men  or  "  Eiweissmilch  "  are  substituted.  In  the  buttermilk  mix- 
tures the  precipitation  of  the  casein  is  brought  about  by  lactic 
acid  bacilli  (Bulgarian  culture).  This  prevents  the  coagulation 
of  the  casein  into  tough  curds.  Lactose  buttermilk  or  lactic  acid 
milk  is  used  in  the  feeding  of  infants  who  have  persistent  green 
stools,  and  in  cases  of  acute  toxic  diarrhea  brought  about  through 
the  action  of  gas  bacillus. 

Buttermilk  is  more  difficult  to  administer  to  babies  than  for- 
mulas made  from  plain  milk  by  reason  of  its  flavor.  However, 
the  results  are  remarkable  in  the  above-mentioned  conditions. 

"  Eiweissmilch  "  is  used  in  atrophic  cases  where  there  are  bad 
green  stools. 

"  Homogenized  Milk."  —  Dr.  Ladd  of  the  Children's  Hospital 
in  Boston  has  presented  many  cases  of  infants  who  showed  an 
intolerance  for  butter  fat.  These  cases  he  has  treated  with  for- 
mulas containing  a  foreign  fat,  usually  olive  oil.  This  milk  is 
subjected  to  a  treatment  which  brings  about  a  more  complete 
emulsification  of  the  fat  than  is  possible  in  cow's  milk,  causing  it 
to  resemble  in  character  the  quality  of  the  mother's  milk.  Homog- 
enized milk  has  been  used  with  success  in  cases  where  it  was 
impossible  to  supply  the  infant  with  breast  milk. 

Technique  of  Milk  Modification.  —  The  absolute  necessity  for 
cleanliness  has  already  been  dwelt  upon  in  respect  to  milk,  and  in 
infant  feeding  the  vigilance  which  must  be  observed  in  the  prepa- 
ration of  the  food  cannot  be  too  strongly  emphasized.  The  milk 
itself  must  be  of  known  purity.  Where  there  is  any  uncertainty 
about  its  source,  it  must  be  sterilized  or  pasteurized  according  to 
the  doctor's  orders.  The  bottles  and  nipples  should  be  washed 
as  soon  as  they  are  used,  first  with  plain  water  to  remove  the 
milk,  then  with  soapsuds  and  a  bottle  brush.  The  bottles  should 
then  be  filled  with  boric  acid  or  bicarbonate  of  soda  solution  until 
needed,  when  they  should  be  emptied  and  placed  in  a  deep  pan 
filled  with  cold  water  and  allowed  to  boil  for  a  few  minutes. 
They  should  not  be  taken  from  the  water  until  they  are  to  be 
filled  with  the  milk  mixture.  The  nipples  are  washed  thoroughly 
and  boiled  once  a  day  and  dropped  into  a  solution  of  boric  acid  or 


176  DIETETICS  FOR  NURSES 

bicarbonate  of  soda  when  not  in  use.  The  plain  black  rubber 
nipples  are  best  as  they  can  easily  be  turned  inside  out  and  cleaned. 
If  the  milk  drops  too  slowly  from  the  bottle,  the  nipple  may  be 
pierced  in  one  or  two  places  w^ith  a  darning  needle. 

The  morning  is  the  best  time  in  which  to  prepare  the  baby's 
food ;  the  milk  has  not  stood  too  long  and  it  is  easier  to  regulate 
the  feedings  if  a  fresh  start  is  made  each  morning.  Let  the  bottles 
and  the  rubber  corks  with  which  they  must  be  stopped  be  boiled 
and  cooled  while  the  milk  mixture  is  being  prepared. 

Preparation  of  Diluents.  —  If  barley  or  oatmeal  water  is  to  be 
used  as  a  diluent,  let  that  be  prepared  first,  that  it  may  be  cool 
before  adding  it  to  the  milk.  Cover  the  table  with  a  clean  cloth 
or  oilcloth,  upon  this  place  the  pitcher  in  which  the  milk  is  to  be 
modified,  have  the  funnel,  milk  dipper,  and  spoon  which  are  to  be 
used  boiled  with  the  bottles,  cover  the  mouth  of  the  pitcher  with 
a  clean  square  of  gauze  or  cheesecloth ;  read  the  formula  carefully 
and  measure  the  sugar,  dextri-maltose,  lactose,  Mellin's  Food,  or 
cane  sugar  as  directed  and  place  it  in  a  clean  glass ;  now  measure 
the  diluent,  water,  oatmeal  water,  barley  water,  or  whey ;  use  part 
of  this  diluent  to  dissolve  the  sugar. 

Measuring  Milk  according  to  Percentage  of  Fat.  —  Now  dip 
off  the  required  layer  of  top  milk,  that  is,  the  layer  containing  the 
desired  percentage  of  fat  and  protein.  Mix  this  thoroughly  and 
dip  out  the  requisite  number  of  ounces  into  the  pitcher.  If  there 
is  not  sufficient  cream  in  one  quart  bottle  to  fill  the  formula,  the 
cream  must  be  dipped  from  a  second  bottle  and  mixed  with  that 
of  the  first  before  it  is  measured  into  the  pitcher.  The  dissolved 
sugar  and  rest  of  the  diluent,  together  with  the  correct  amount  of 
limewater,  are  strained  into  the  pitcher,  mixed  thoroughly,  and 
strained  through  the  absorbent  cotton  lining  the  funnel  into  the 
bottles,  allowing  the  correct  number  of  ounces  for  each  feeding  in 
every  bottle. 

Pasteurizing  the  Milk.  —  The  corks  are  then  adjusted,  the 
bottles  placed  in  the  pastuerizer  *  and  pasteurized  for  the  desired 

8  There  are  a  number  of  pasteurizers  on  the  market ;  one  sold  by  the  Walker 
Gordon  Laboratory  and  one  designed  by  Dr.  R.  G.  Freeman  of  New  York  are  both 
satisfactory. 


INFANT  FEEDING 


177 


number  of  minutes.  The  water  in  the  pasteurizer  must  be  cold 
in  the  beginning  and  the  rise  of  temperature  recorded  on  the  ther- 
mometer, which  is  adjusted  at  a  convenient  place  in  the  pas- 
teurizer where  the  scale  can  be  read  easily.  If  the  temperature  of 
the  water  is  too  high,  add  cold  water  and  lower  the  flame  beneath 
the  pasteurizer.  When  the  desired  number  of  minutes  has 
elapsed,  lift  the  bottle  rack  above  the  water  for  a  few  minutes 
and  allow^  a  stream  of  cold  water  to  flow  into  the  pasteurizer,  tak- 
ing care  not  to  chill  the  bottles  too  suddenly  or  they  will  crack. 
Cool  the  bottles  as  quickly  as  possible  and  place  on  ice  until  needed, 
warming  the  bottle  of  milk  as  needed  in  warm  water. 


SELECTED   FORMULAS 

The  following  formulas,  adapted  from  Holt's  "  Care  and  Feed- 
ing of  Children,"  may  prove  of  use  in  the  feeding  of  normal  babies  : 

1.    Series ;  Fat  to  Protein  3:1. 

Primary  Formula,  10%  milk,  fat  10%,  sugar  4.3%,  protein 
3.3%  obtained  (1)  as  upper  third  of  quart  bottle  or  (2)  equal  parts 
16%  cream  and  milk. 

Derived  Formulas,  giving  quantities  in  20-ounce  mixture  :  milk 
sugar  1  ounce,  limewater  1  ounce,  water  sufficient  quantity  added 
to  make  20  ounces. 


Fat 

Sugar 

Protein 

Per  Cent 

Per  Cent 

Per  Cent 

1.    With  2  oz.  10%  milk     .     . 

1.00 

5.50 

'  0.33 

2.   WithSoz.  10%  milk     .     . 

1.50 

5.50 

0.50 

3.   Witli4oz.  10%  milk     .     . 

2.00 

6.00 

0.66 

4.   With  5  oz.  10%,  milk     .     . 

2.50 

6.00 

0.83 

5.   WithOoz.  10  %o  milk     .     . 

3.00 

6.00 

1.00 

6.   With  7  oz.  10%  milk     .     . 

3.50 

6.50 

1.16 

In  each  formula  the  proportion  of  fat  to  protein  is  3:1,  the 
sugar  1  ounce  in  20  or  1  tbs.  in  8  ounces  gives  5.5%  for  lower  for- 

N 


178 


DIETETICS  FOR  NURSES 


mulas  and  6.5%  for  higher  formulas ;  sufficient  water  is  added  to 
bring  the  mixture  up  to  the  desired  number  of  ounces. 

2,   Series;  Fat  to  Protein  2:1. 

Primary  Formula,  7%  milk,  fat  7%,  sugar  4.4%,  protein  3.5% 
obtained  (1)  from  upper  half  of  quart  bottle  of  milk  or  (2)  by  using 
three  parts  milk  and  one  part  16%  cream. 

Derived  Formulas,  giving  quantities  for  a  20-ounce  mixture : 
milk  sugar  1  ounce,  limewater  1  ounce,  water  sufficient  quantity 
added  to  make  20  ounces. 


Fat 

Sugar 

Protein 

Per  Cent 

Per  Cent 

Per  Cent 

1.   With    3oz.  7%  milk     .     . 

1.00 

5.50 

0.50 

2.   With    4oz.  7%  milk 

1.40 

5.75 

0.70 

3.   With    5  oz.  7%  milk 

1.75 

6.00 

0.87 

4.   With    60Z.  7%  milk 

2.10 

6.00 

1.05 

5.   With    7  oz.  7%  milk 

2.50 

6.50 

1.25 

6.   With    8  oz.  7%  milk 

2.80 

6.50 

1.40 

7.   With    9  oz.  7%  milk 

3.15 

7.00 

1.55 

8.   With  10  oz.  7%  milk 

3.50 

7.00 

1.75 

9.   With  12  oz.  7%  milk 

4.00 

7.00 

2.00 

The  exact  fat  per  cent  is  obtained  by  taking  one-third  of  the 
number  of  ounces  of  top  milk  in  a  20-ounce  mixture  and  adding 
0.15  to  result.  There  may  be  a  slight  variation  but  the  amount 
is  too  slight  to  make  any  appreciable  difference.  The  percent- 
age of  protein  in  each  case  is  one-half  the  fat.  The  amount  of 
sugar  used  is  one  ounce  in  twenty  until  the  food  is  half  milk ; 
then  one  in  twenty-five  or  one  tablespoonful  to  each  ten  ounces 
will  give  the  correct  amount.  One  ounce  of  limewater  is  allowed 
to  the  entire  twenty  ounces  of  food  and  water  or  other  diluent. 

3.   Series ;  Fat  to  Protein  8 :  7. 

Primary  Formula,  plain  milk,  fat  5%,  sugar  4.5%,  protein  3%. 

Derived  Formulas,  giving  quantities  for  20-ounce  mixture: 
milk  sugar  1  oz.,  limewater  1  oz.,  water  of  sufficient  quantity 
added  to  make  20  ounces : 


INFANT  FEEDING 


179 


Fat 
Per  Cent 

Sugar 
Per  Cent 

Protein 
Per  Cent 

1.  With    5  oz.  plain  milk 

2.  With    6  oz.  plain  milk 

3.  With    8  oz.  plain  milk 

4.  With  10  oz.  plain  milk 

1.00 
1.20 
1.60 
2.00 

6.00 
6.00 
6.50 
7.00 

0.87 
1.00 
1.40 
1.75 

Milk  sugar  ^  oz.,  limewater  ^  oz.,  water  of  sufficient  quantity 
added  to  make  20  ounces : 


Fat 

Sugar 

Protein 

5.  With  12  oz.  plain  milk 

6.  With  14  oz.  plain  milk 

7.  With  16  oz.  plain  milk 

2.40 
2.80 
3.20 

5.00 
5.50 
5.50 

2.10 
2.50 
2.80 

Changing  the  Formula.  —  It  is  often  found  necessary  to  change 
the  formula  when  using  artificial  feeding  for  infants,  and  under 
these  circumstances  it  is  necessary  to  know  the  percentages  of 
the  food  constituents  contained  in  the  formula  already  in  use. 
For  this  purpose  the  following  method,  quoted  from  "  Diseases  of 
Nutrition  and  Infant  Feeding,"  ^  is  included  : 

Morse  and  Talbot's  Method.  —  Suppose  that  a  baby  is  taking 
a  food  made  up  of  — 


Gravity  cream 
Skimmed  milk 
Limewater 
Barley  water 
Milk  sugar 


12  ounces 

18  ounces 

6  ounces 
12  ounces 

4  rounded  tablespoonfuls 


"  The  barley  water  is  made  with  two  teaspoonfuls  of  barley 
flour  in  a  pint  of  water.  The  total  quantity  of  the  mixture  is  48 
ounces.  Gravity  cream  contains  16%  fat.  Twelve  ounces  of 
gravity  cream  in  a  48-ounce  mixture  will  give,  therefore,  if  of 
16%  of  fat,  or  4%  fat.     Both  gravity  cream  and  skimmed  milk 


'  "Diseases  of  Nutrition  and  Infant  Feeding, 

Talbot. 


pp.  225  and  226,  by  Morse  and 


180  DIETETICS  FOR  NURSES 

contain  3.20%  protein.  There  are  30  ounces  of  gravity  cream 
and  skimmed  milk  in  the  mixture ;  30  ounces  in  a  48-ounce  mix- 
ture will  give  If  of  3.20%  of  protein,  or  2.00%  of  protein.  Both 
gravity  cream  and  skimmed  milk  also  contain  4.50%  of  sugar. 
Thirty  ounces  of  gravity  cream  and  skimmed  milk  in  a  48-ounce 
mixture  will  therefore  furnish  ff  of  4^  which  is  the  same  as  ff  of 
f  or  almost  3.00%  of  milk  sugar.  Four  rounded  tablespoonfuls 
of  milk  sugar  are  equal  to' two  ounces.  Two  ounces  of  sugar  in  a 
48-ounce  mixture  is  equal  to  A  of  100%  or  4%.  The  total  per- 
centage of  sugar  is,  therefore,  7%.  Two  teaspoonfuls  of  barley 
flour  in  a  pint  of  water  makes  a  1 .50%  decoction  of  starch.  Twelve 
ounces  of  barley  water  of  this  strength  in  a  48-ounce  mixture  will 
give  a  of  1.50%  or  about  0.35%  starch.  There  are  six  ounces  of 
limewater  in  the  mixture  and  30  ounces  of  gravity  cream  and 
skimmed  milk.  -^  of  100%  is  20%.  The  limewater  is,  there- 
fore, 20%  of  the  milk  and  cream.  The  mixture  thus  contains  4% 
fat,  7%  sugar,  2%  protein,  and  0.35%  starch,  while  the  limewater 
is  in  the  proportion  of  20%  of  the  cream  and  milk." 

If,  therefore,  the  nurse  will  follow  out  the  plan  suggested  by 
Drs.  Morse  and  Talbot,  it  should  be  a  simple  matter  to  change 
the  percentage  of  any  of  the  food  constituents  in  any  formula. 

Computing  the  Fuel  Value.  —  In  computing  the  fuel  values  of  a 
formula,  it  is  necessary  to  know  the  number  of  grams  of  each 
chemical  combination  in  the  mixture  and  multiply  these  by  their 
fuel  factors.  To  find  if  the  formula  is  not  furnishing  the  requisite 
number  of  calories  to  cover  the  energy  and  nitrogen  requirements, 
it  is  necessary  only  to  turn  to  the  table  showing  the  requirements 
for  the  different  ages  to  gain  some  idea  as  to  how  far  the  formula 
is  conforming  to  the  average  requirements.  It  must  be  under- 
stood that  it  is  impossible  to  lay  down  a  hard  and  fast  law  in 
making  the  formulas.  Each  infant  has  slightly  different  require- 
ments. One  may  be  strong  and  active,  expending  much  energy, 
while  another  not  so  robust  nor  so  active  uses  his  energy  for  stor- 
age purposes.  The  first  youngster's  energy  requirements  are 
necessarily  greater  than  those  of  the  more  phlegmatic  baby,  since 
the  one  uses  his  energy  for  physical  activities  while  the  other 


INFANT  FEEDING  181 

stores  it  up.  The  nervous,  highly-strung  baby  who  cries  much 
and  sleeps  little  has  an  energy  requirement  in  excess  of  that  of  the 
baby  who  is  quiet  when  awake  and  who  sleeps  the  greater  part 
of  the  twenty-four  hours.  The  following  scheme  i°  is  suggested, 
using  whole  milk  as  a  basis  for  the  feeding  of  normal  babies  during 
the  first  year. 

Administration  of  Water.  —  Water  is  given  every  four  hours 
•  during  the  first  day  in  quantities  of  from  one  to  two  ounces.  On 
the  second  to  fourth  days  three  ounces  of  milk,  seven  ounces  of 
water,  two  teaspoonfuls  of  milk  sugar  or  dextri-maltose  is  divided 
into  seven  feedings.  On  the  fifth  to  seventh  days,  four  ounces  of 
milk,  eight  ounces  of  water,  three  teaspoonfuls  of  milk  sugar, 
divided  into  seven  feedings.  Eighth  day  to  end  of  third  month : 
beginning  with  five  ounces  of  milk,  ten  ounces  of  water,  and  one 
and  one-half  tablespoonfuls  of  milk  sugar,  increase  the  milk  one- 
half  ounce  every  four  days,  ^he  water  one-half  ounce  every  eight 
days,  the  milk  sugar  by  one-half  tablespoonful  every  two  weeks. 
On  the  sixteenth  day  the  formula  requires  six  ounces  of  milk, 
ten  and  one-half  ounces  of  water,  and  two  tablespoonfuls  of  milk 
sugar  divided  into  seven  feedings.  On  the  twentieth  day  the 
formula  is  changed  to  six  and  one-half  ounces  of  milk,  the  water 
and  sugar  increased  in  proportion,  making  six  and  one-half  ounces 
of  milk,  ten  and  one-half  ounces  of  water,  and  two  tablespoonfuls 
of  milk  sugar  or  dextri-maltose.  At  this  rate  of  increase,  the 
infant  receives  by  the  end  of  the  third  month  approximately 
sixteen  ounces  of  milk,  sixteen  ounces  of  water,  and  four  and 
one-half  tablespoonfuls  of  milk  sugar,  which  is  divided  into  six 
instead  of  seven  feedings. 

Strengthening  the  Formula.  —  The  increase  of  milk  is  made  at 
the  rate  of  one-half  ounce  every  six  days,  while  the  sugar  remains 
stationary  at  four  and  one-half  tablespoonfuls  each  day  and  the 
amount  of  the  water  is  decreased  at  the  rate  of  one-half  ounce 
every  two  weeks. ^^ 

"Adapted  from  "Save  the  Babies,"  by  Holt  and  Shaw. 

1^  If  food  does  not  digest  or  if  the  stools  are  found  to  contain  undigested  curds, 
i  teaspoonful  of  barley  flour  n>ay  be  cooked  in  the  water  for  20  minutes,  the  amount 
of  water  lost  by  evaporation  being  added  to  cool  the  mixture. 


182  DIETETICS  FOR  NURSES 

By  the  end  of  the  sixth  month  the  baby  is  receiving  twenty- 
four  ounces  of  milk,  twelve  ounces  of  water,  and  four  and  one-half 
tablespoonfuls  of  milk  sugar,  divided  into  five  feedings.  The  in- 
crease of  one-half  ounce  of  milk  is  now  made  every  week,  while 
the  water  is  reduced  one-half  ounce  every  two  weeks  and  the  milk 
sugar  to  three  tablespoonfuls  each  day. 

Orange  Juice.  —  During  the  seventh  month  to  the  end  of  the 
ninth  month  from  one  to  two  tablespoonfuls  of  strained  orange 
juice  may  be  given  midway  between  the  two  morning  feedings. 
This  is  introduced  to  keep  the  bowels  in  good  condition,  and  to 
act  as  a  preventive  measure  against  scurvy,  which  may  develop 
if  pasteurized  milk  is  used  exclusively.  Barley  flour  may  likewise 
be  used  at  this  time,  beginning  with  1^  tablespoonfuls  (f  of  an 
ounce)  and  increasing  to  3  tablespoonfuls.  This  is  boiled  in  the 
water  which  forms  part  of  the  formula  for  the  day. 

Tenth  Month  to  End  of  Twelfth  Month.  —  At  the  end  of  the 
ninth  month  the  baby  is  receiving  approximately  30  ounces  of  milk, 
8  ounces  of  water  cooked  with  3  tablespoonfuls  of  barley  flour,  and 
3  tablespoonfuls  of  milk  sugar  divided  into  5  feedings.  The 
orange  juice  is  continued  as  directed.  The  milk  is  now  increased 
one  ounce  per  month  and  the  sugar  decreased  one  tablespoonful 
per  month.  The  3  tablespoonfuls  of  barley  flour  are  cooked  in 
8  ounces  of  water  and  added,  and  the  orange  juice  may  be 
increased  to  3  tablespoonfuls  unless  the  bowels  are  already  loose. 
After  one  feeding  of  milk  is  given,  the  soft-cooked  yolk  of  an  egg  ^ 
may  be  fed  or  a  small  piece  of  stale  bread  crust  may  be  given  the 
baby  to  chew.  According  to  Holt  and  Shaw,  no  other  food  must 
be  given  during  the  first  year.  Other  authorities,  however,  include 
strained  cereals,  oatmeal,  cream  of  wheat,  rice,  or  farina  during 
the  last  three  months  of  the  first  year. 

Adding  Semi-solids  to  Diet.  —  At  fourteen  months  the  baby 
may  have  milk-toast,  using  part  of  its  milk  for  this  purpose;  a 
part  of  the  milk  may  likewise  be  made  into  junket.     Prune  pulp 

1'  Morse  and  Talbot  advise  the  giving  of  eggs  to  be  deferred  until  the  baby  is 
18  months  old,  giving  one  egg  every  other  day  unless  it  disagrees,  increasing  thia 
to  one  egg  a  day  by  the  time  the  child  is  2  years  old. 


INFANT  FEEDING  183 

and  juice  and  the  soft  part  of  a  well-baked  apple  may  be  given  at 
this  time. 

Many  specialists  in  the  feeding  of  infants  begin  the  feeding  of 
more  solid  foods  at  the  early  age  of  six  months  and  continue  to  the 
ninth  month,  at  this  time  giving  the  following  scheme  of  feeding 
as  a  guide : 

Scheme  for  Adding  Solids  to  Infants'  Diet.  — 

From  9th  to  15th  month : 

6  A.M.  —  Milk  formula  (bottle). 

8  A.M.  —  Orange  juice  ^  ounce,  or  prune  pulp  or  prune  juice. 
10  A.M.  —  Bottle,  cereal  (strained)  and  bread  and  butter  or 
zwieback. 

2  P.M.  —  Mutton,  chicken,  or  veal  soup  cooked  with  cereal ; 

small  portion  of  baked  potato,  small  portion  of 
strained  spinach  or  carrots;   orange  gelatine  or 
cornstarch  pudding. 
6  P.M. —  Bottle. 

From  15  months  to  2J  years : 

8  A.M.  —  Stewed  fruit  or  orange  juice ;  cereal ;  crisp  bacon, 
alternate  with  soft-cooked  or  poached  egg; 
bread  and  butter  or  toast,  milk  or  weak  cocoa. 
12  or  1  P.M. — Meat  or  vegetable  soup  thickened  with  cereal; 
lamb  chop,  scraped  beef  or  chicken  or  beef 
juice;  baked  or  mashed  potato;  strained 
spinach;  carrots;  turnips  or  celery;  gelatine, 
custard,  or  cornstarch  pudding. 

3  P.M.  —  Crackers  and  milk. 

6  or  7  P.M.  —  Bread  and  milk  or  cereal;  baked  apple  or  apple 
sauce. 

From  3  to  6  years : 

8  A.M.  —  Stewed  fruit  or  orange ;  cereal ;  bacon  or  egg  (soft- 
cooked  or  poached) ;  bread  and  butter ;  milk 
or  cocoa. 


184  DIETETICS  FOR  NURSES 

12  M.  —  Soup ;  lamb  chop,  scraped  beef,  chicken,  or  roast 
meats ;  potato  ;  all  vegetables  ;  celery,  lettuce ; 
light  desserts  :  custards,  gelatine,  lady  fingers. 

3  P.M.  — Milk;   fruit  and  crackers. 

6  P.M.  —  Milk  or  cocoa ;  stewed  fruit ;  bread  and  butter ; 
cereals;  eggs. 

Morse  and  Talbot  advise  baked  potato,  plain  boiled  macaroni, 
rice  and  wheat  germ,  bread  and  butter,  baked  custard,  plain  blanc- 
mange, and  plain  boiled  tapioca  to  be  given  when  the  child  is  1^ 
years  old.  When  the  child  is  nearly  two  years  old  they  add  meat 
in  the  most  digestible  forms,  such  as  the  white  meat  of  chicken, 
lamb  or  mutton  chops,  and  scraped  beef. 

The  following  dietary  is  suggested  for  a  child  two  years  old :  ^^ 

"  Whole  milk,  butter,  mutton  broth,  chicken  broth,  beef  juice, 
soft-cooked  eggs,  dropped  eggs,  white  meat  of  chicken,  lamb  or 
mutton  chops,  scraped  beef,  French  bread,  stale  bread,  toasted 
bread,  whole  wheat  bread,  milk  toast,  zwieback,  plain  white 
crackers,  plain  Educator  crackers,  barley  jelly,  oatmeal,  cream  of 
wheat,  wheat  gerni,  Ralston's  Farina,  rice,  baked  potato,  plain 
boiled  macaroni,  orange  juice,  baked  apples,  stewed  prune  pulp 
and  juice,  junket,  baked  custard,  cornstarch  pudding,  plain  blanc- 
mange, plain  tapioca.  It  is  not  advisable,  as  a  rule,  to  begin 
green  vegetables  until  the  baby  is  2^  years  old.*' 

It  will  be  seen  in  the  foregoing  dietaries  how  authorities  differ 
in  their  beliefs  as  to  the  requirements  of  the  child.  The  dietaries 
included  in  this  text  are  selected  from  those  used  in  different  parts 
of  the  country  by  physicians  who  have  successfully  cared  for  the 
infants  and  children  under  their  charge. 

THE   FEEDING   OF   PREMATURE   INFANTS 

The  digestion  of  premature  infants  is  naturally  not  as  strong 
as  that  of  infants  born  at  term.  Very  little  is  positively  known, 
but  the  consensus  of  opinion  goes  to  show  that  in  the  majority  of 
cases  the  tolerance  for  sugar  is  greater  than  that  of  either  the  pro- 

13  "Diseases  of  Nutrition  and  Infant  Feeding,"  p.  236,  by  Morse  and  Talbot. 


INFANT  FEEDING  185 

teins  or  fats.  The  loss  of  heat  is  relatively  greater  in  proportion 
to  its  surface  area  in  small  than  in  large  bodies.  This  is  a  well- 
known  fact,  hence  the  premature  baby  must  require  more  food  in 
proportion  to  its  weight  than  the  baby  who  is  born  at  the  normal 
time.  Then,  too,  as  the  premature  infant  is  thinner  he  does  not 
keep  warm  like  the  older  infant,  and  this  must  be  taken  into  con- 
sideration in  feeding  him.  Breast  milk  is  of  course  by  far  the  best 
food  for  such  babies,  not  only  because  its  constituents  are  in  a 
more  available  form  for  the  feeble  digestive  organs,  but  because 
the  mother's  milk  furnishes  a  resistance  which  is  lacking  in  even 
the  most  carefully  modified  of  milk  formulas. 

Energy  Requirements  of  Premature  Infants.  —  Experiments 
made  upon  premature  infants  have  proved  that  the  caloric  needs 
of  these  babies  are  greater  than  in  the  case  of  full-time  babies ; 
that  is,  they  require  more  per  kilogram,  of  body  weight.  Accord- 
ing to  Morse  ^^  most  premature  babies  need  120  calories  per 
kilogram  of  body  weight.  But  there  are  many  exceptions,  some 
thriving  on  as  little  as  70  calories  per  kilogram.  "  No  attempt 
should  be  made  to  reach  120  calories  per  kilogram  during  the  first 
few  days.  Thirty  calories  per  kilogram  is  as  much  as  is  wise  to 
give  in  the  first  24  hours  of  feeding.  This  amount  should  be 
gradually  increased  each  day,  watching  carefully  for  symptoms  of 
indigestion  and  diminishing  it  if  these  appear.  One  hundred  and 
twenty  calories  per  kilogram  can  be  given  in  about  10  days."  ^^ 

Necessary  Dilution.  —  Even  breast  milk  must  be  diluted  with 
an  equal  amount  of  water  or  a  3%  sugar  solution.  The  amount 
of  milk  should  be  increased  and  the  amount  of  dilution  decreased 
until  the  undiluted  breast  milk  is  given  in  four  or  five  days.  Like 
older  babies,  the  next  best  food  for  premature  babies  is  the  properly 
modified  cow's  milk,  but  exceeding  care  will  have  to  be  observed, 
as  these  babies  are  more  easily  upset  than  older  and  stronger  ones. 

Premature  Infant  Feeding.  —  The  following  method  of  feeding 
may  be  suggested,  keeping  in  mind  that  it  is  an  easy  matter  to 

1^  Morse:  "American  Journal  of  Obstetrics,"  1905.  Hess:  "American  Journal 
Diseases  of  Children,"  1911. 

""Diseases  of  Nutrition  and  Infant  Feeding,"  p.  238,  by  Morse  and  Talbot. 


186  DIETETICS  FOR  NURSES 

increase  the  strength  of  a  mixture  if  the  baby  shows  the  need  of 
such  an  increase.  The  premature  baby  is  rarely  strong  enough  to 
take  the  breast. 

Method  of  Administering  Milk.  —  The  most  satisfactory  method 
of  administering  the  food  in  such  cases  is  by  means  of  the  Brick 
feeder,  which  consists  of  a  graduated  glass  tube,  open  at  either  end. 
On  the  small  end  is  placed  a  small  nipple  like  those  seen  on  medi- 
cine droppers ;  this  one  is  perforated  and  goes  into  the  mouth  of 
the  baby.  A  large  rubber  finger  cot  is  attached  to  the  other  end 
of  the  tube.  The  milk  is  forced  into  the  mouth  by  pressing  the 
finger  cot.  In  case  the  infant  is  too  feeble  even  for  this  method 
of  feeding,  the  desired  amount  is  dropped  into  the  mouth  from  a 
medicine  dropper;  5  c.c.  (about  1  dram  or  1  teaspoonful)  of 
diluted  milk  being  given  at  each  feeding.  This  amount  is  increased 
gradually  from  day  to  day. 

Whey  Mixtures.  —  Whey  mixtures  have  been  found  to  meet 
the  needs  of  premature  infants  more  efficiently  than  ordinary 
mixtures.  As  the  proteins  in  whey  are  in  a  more  digestible  form, 
they  throw  less  work  on  the  immature  digestive  apparatus.  As  a 
rule  the  casein  and  whey  are  in  proportion  of  1 :  1 . 

The  following  formulas  ^^  show  the  amounts  in  which  the 
food  constituents  are  combined  and  are  suitable  for  premature 
babies : 

Fat 1.00% 

Milk  sugar 4.00% 

Total  proteins  .     .     .     .  0.25% 

Limewater 25%  of  cream  and  milk  mixtm-e 

or 

Fat 1.00% 

Milk  sugar 4.50% 

Total  proteins    ....  0.50% 

Limewater         ....        25%  of  cream  and  milk  mixture 

PROPRIETARY  FOODS 

A  word  as  to  the  use  of  Proprietary  Infant  Foods :  These  pre- 
pared foods  may  be  classified  under  four  heads,  as  follows  :  (1)  con- 

i«  "Diseases  of  Nutrition  and  Infant  Feeding,"  p.  239,  by  Morse  and  Talbot. 


INFANT  FEEDING  187 

densed  milks ;  (2)  malted  foods,  those  consisting  chiefly  of  carbo- 
hydrates in  the  form  of  maltose  and  dextrins ;  (3)  those  consist- 
ing almost  entirely  of  starch,  and  (4)  those  composed  partly  of 
soluble  and  partly  of  insoluble  carbohydrates. 

(1)  Condensed  milk  may  be  sweetened  or  unsweetened.  These 
milks  are  never  given  undiluted,  the  directions  calling  for  one  part 
condensed  milk  to  nine  parts  water,  which  gives  a  mixture  con- 
taining 0.90%  fat,  5.49%  sugar,  and  0.80%  protein  if  "  Eagle 
Brand  "  Condensed  Milk  is  used.^^ 

(2)  Malted  Foods :  Mellin's  Food  and  malted  milk  are  examples 
of  this  group.  These  foods  contain  the  carbohydrates  in  soluble 
form  and  when  added  to  milk  make  an  acceptable  addition,  as 
they  furnish  the  carbohydrates  in  the  most  digestible  form. 
When  fed  alone,  diluted  only  with  water,  they  result  in  a  mixture 
deficient  in  both  fat  and  protein. 

(3)  Imperial  Granum  is  an  example  of  this  group,  and  there  are 
several  others  with  similar  compositions.  These  foods  are  very 
much  like  wheat  flour  which  has  been  subjected  to  heat,  changing 
to  a  small  extent  the  starch  to  dextrose  and  dextrin. 

(4)  Nestl6's  Food,  Eskay's  Albumenized  Food,  and  Allenbury's 
Food  are  examples  of  this  group,  each  containing  sugar  and  a  per- 
centage of  starch.  Upon  dilution  with  water,  the  amount  of  fat 
in  the  mixture  is  just  a  trace. 

Incomplete  Foods  as  a  Source  of  Danger.  —  The  ease  with 
which  the  majority  of  these  foods  are  prepared  and  the  way  in 
which  they  agree  with  the  baby  constitute  the  chief  danger  of 
their  use.  If  they  are  added  to  milk,  with  the  exception  of  the 
condensed  milks,  they  result  in  a  modified  milk  containing  the 
carbohydrates  in  a  more  or  less  digested  form.  But  they  are  ex- 
pensive, and  give  no  better  result  as  a  rule  than  a  carefully  modified 
milk  containing  a  cereal  gruel. 

The  giving  of  foods  like  malted  milk  alone  is  dangerous  because 
they  are  deficient  in  some  of  the  most  necessary  constituents,  and 
babies  fed  in  this  way,  while  growing  fat,  are  apt  to  have  soft  or 
brittle  bones  and  muscular  tissue  higher  in  fat  and  water  than  in 

"  "Diseases  of  Nutrition  and  Infant  Feeding,"  by  Morse  and  Talbot. 


188  DIETETICS  FOR  NURSES 

protein,  so  that  they  do  not  grow  and  develop  in  a  normal  way, 
and  when  they  are  attacked  by  the  diseases  so  prevalent  in  the 
early  years  of  life,  they  succumb  rapidly,  because  the  resistance 
given  by  a  properly  modified  food  is  lacking. 

Condensed  milks  act  in  a  like  manner.  That  is,  in  the  sweetened 
milks  the  carbohydrate  content  is  far  in  excess  of  the  needs,  and 
the  proteins  and  fats  are  deficient,  so  that  while  the  baby  fattens 
he  does  not  receive  the  building  foods  commensurate  with  his 
body  requirements.^^ 

Many  mothers  adopt  the  use  of  these  foods  because  they  mean 
less  work  than  in  modifying  the  milk  properly,  but  the  nurse  should 
point  out  the  facts  just  mentioned,  explaining  that  while  these 
proprietary  infant  foods  are  undoubtedly  valuable  at  times  to 
fill  a  place  when  the  milk  formula  has  not  proved  satisfactory,  the 
use  of  these  foods  as  a  regular  custom  is  expensive,  not  only  from 
a  financial  standpoint  but  from  a  standpoint  of  health,  since  their 
disadvantages  far  outweigh  their  advantages  in  the  long  run. 

SUMMARY 

Breast  Milk  as  a  Food.  —  The  superiority  of  breast  milk  over 
any  other  known  food  cannot  be  too  strongly  emphasized. 

Regularity  in  Feeding.  —  The  absolute  need  for  regularity  in 
feeding  —  "  feeding  by  the  clock  "  and  not  by  guess  or  when  the 
baby  cries. 

Indications  of  Health.  —  The  normal  growth  and  development 
to  be  used  as  guides  as  to  the  physical  well-being  of  the  infant; 
also  as  an  indication  of  the  use  of  the  proper  modification  of  milk 
for  the  individual  needs  of  the  child. 

Dilution.  —  The  amount  of  dilution  necessary  —  cereal  waters, 
whey,  etc.  —  to  increase  the  digestibility  and  nutrient  values  of 
the  formula. 

The  Addition  of  Alkali.  —  The  addition  of  alkalies  to  milk  for- 
mulas to  accomplish  a  like  purpose. 

18  The  proprietary  foods  on  the  market  are  many,  but  those  given  above  as 
suggested  by  Morse  and  Talbot  represent  the  best  known  infant  foods. 


INFANT  FEEDING  189 

Milk  Sugar,  Malt  Sugar,  Cane  Sugar.  —  The  use  of  the  different 
sugars,  namely,  dextri-maltose_,  lactose,  or  cane  sugar  under  various 
circumstances  as  the  condition  of  the  infant  demands. 

Substitutes  for  Whole  Milk.  —  The  substitution  of  different 
milks,  such  as  lactic  acid  milk,  Bulgarian  culture  buttermilk, 
Eiweissmilch,  cream  and  whey  mixtures,  as  the  individual  needs 
of  the  infant  demand. 

Technique  of  Milk  Modifications.  —  The  absolute  need  for  the 
nurse  to  understand  the  technique  of  milk  modification  before 
attempting  the  care  of  an  artificially  fed  infant. 

Percentage  Computation.  —  A  knowledge  of  percentage,  that 
an  accurate  computation  of  a  formula  may  be  accomplished. 

Preparation  of  Food.  —  A  sufficient  knowledge  of  food  prepa- 
ration to  enable  the  mu-se  to  prepare  any  food  which  may  be 
deemed  necessary  by  the  physician  for  the  welfare  of  the  child. 

Water.  —  The  importance  of  giving  the  baby  water  aside  from 
that  used  in  modifying  the  milk.  Many  babies  cry  from  thirst 
whenlhey  are  believed  to  be  crying  from  hunger  or  temper. 

Increasing  the  Diet.  —  The  necessity  for  increasing  the  amount 
and  strength  of  the  formula  with  the  age,  growth,  and- develop- 
ment of  the  child  by  the  addition  of  solid  food  as  soon  as  the 
physician  deems  it  advisable. 

Feeding  Premature  Infants.  —  The  method  of  feeding  a  pre- 
mature infant  differs  from  that  employed  in  feeding  an  infant 
born  at  term  :  (a)  because  its  development  has  not  progressed  so 
far;  (6)  because  its  digestive  apparatus  being  more  or  less  im- 
mature, food  handled  with  ease  by  an  older  baby  will  be  totally 
unfit  for  the  premature  one,  both  as  to  quality  and  quantity. 

Wet  Nurse.  —  The  advisability  of  procuring  a  wet  nurse  when 
the  mother  is  unable  to  nurse  the  infant,  (a)  on  account  of  the 
more  digestible  character  of  the  food  constituents,  especially  the 
proteins,  in  mother's  milk  over  those  of  cow's  milk ;  (6)  on  account 
of  the  resistance  furnished  by  the  natural  food  which  has  been 
proved  to  be  very  much  greater  than  that  furnished  by  any  other 
food,  no  matter  how  carefully  the  modification  of  the  milk  is 
made. 


190  DIETETICS  FOR  NURSES 

Premature  Infants.  —  Their  caloric  needs  are  greater  than  in 
full-term  babies,  hence  their  food  must  be  adjusted  to  meet  these 
needs. 

In  fact  the  nurse  must  have  an  understanding  of  the  behavior 
of  foods  in  the  metabolism  of  infancy  and  the  laws  which  govern 
their  use  in  the  organism  of  the  child. 


CHAPTER  XI 

CARE  AND  FEEDING  OF   INFANTS  AND  CHILDREN 
IN  ABNORMAL  CONDITIONS 

Digestive  Disturbances.  —  It  is  a  well-established  fact  that 
artificially  fed  infants  are  more  subject  to  disturbances  due  to 
diet  than  breast-fed  infants,  the  digestional  disturbances  of 
the  latter  yielding  more  readily  to  treatment.  As  a  rule,  with 
the  breast-fed  baby  it  is  largely  a  question  of  adjusting  the  diet 
of  the  mother,  of  increasing  the  fluid  in  her  diet,  of  seeing  that  she 
takes  the  requisite  amount  of  exercise  in  the  open  air,  and  of 
lengthening  the  intervals  between  feedings  or  of  giving  the  baby 
water  just  before  putting  him  to  the  breast.  With  the  artificially 
fed  infant  it  is  an  entirely  different  proposition. 

Causes  in  Artificially  Fed  Infants.  —  The  digestive  disturbances 
may  arise  from  any  one  of  half  a  dozen  or  more  causes.  The 
constituents  in  the  milk  may  be  in  the  wrong  proportion.  The 
amount  given  at  a  feeding  may  be  too  great  or  too  little.  The 
dilution  may  be  too  great  or  too  small  to  meet  the  needs  of  the 
infant.  Or  the  milk  may  contain  the  microorganisms  which  bring 
about  fermentation  or  putrefaction.  Any  or  all  of  these  causes 
may  assail  the  artificially  fed  baby.  Consequently,  all  the  care 
that  can  be  exercised  must  be  resorted  to  in  the  feeding  of  these 
babies,  not  only  after  digestional  disturbances  arise,  but  as  a 
means  of  their  prevention.  In  the  preceding  chapter  the  methods 
generally  used  in  the  feeding  of  normal  infants  were  discussed. 
We  now  proceed  to  the  feeding  under  abnormal  or  pathological 
conditions. 

Errors  in  Diet.  —  The  majority  of  the  ills  from  which  the  baby 
suffers  can  be  traced  primarily  to  errors  in  diet  and  in  most  of 
these  cases  the  treatment  consists  chiefly  in  adjusting  the  formula 

191 


192  DIETETICS  FOR  NURSES 

to  suit  the  condition.  As  a  rule,  these  errors  may  be  placed  under 
two  heads :  those  that  are  brought  on  by  underfeeding  and  those 
induced  by  overfeeding.  The  pathological  conditions  arising  from 
underfeeding  are  due  not  only  to  a  lack  of  food,  but  chiefly  to  the 
improper  balancing  of  the  different  food  constituents  in  the  for- 
mula. As  has  already  been  stated,  so  much  food  is  required  to 
cover  the  energy  expenditures,  so  much  for  maintenance,  and  so 
much  for  storage  for  the  growth  and  development  necessary  during 
the  entire  period  from  birth  to  maturity.  These  constituents  must 
be  regulated  to  the  individual  needs  of  the  infant. 

Over-  and  Under-dilution.  —  If  the  dilution  is  too  great,  the 
infant,  while  receiving  the  correct  amount  of  the  mixture,  may  have 
the  necessary  food  constituents  so  reduced  as  to  have  them  fail 
completely  to  do  their  appointed  work  in  the  body.  Or  if  the 
amount  of  diluent  is  too  small  the  baby  may  be  receiving  too 
strong  a  mixture,  and  develop  nutritional  disturbances  therefrom. 
Under  the  first  head  the  child  suffers  from  underfeeding ;  the  appe- 
tite is  satisfied  before  enough  of  the  actual  food  is  ingested  to  meet 
his  various  needs.  However,  it  is  probable  that  the  artificially 
fed  infant  suffers  from  the  results  of  over-,  rather  than  of  under- 
feeding. 

DISEASES  DUE  TO   ERRORS  IN  DIET 

Gastro-intestinal  disturbances,  colic,  enterocolitis,  colitis,  etc., 
rickets,  scurvy,  nephritis,  and  diabetes  are  among  the  diseases 
most  apt  to  develop  from  injudicious  feeding,  and  in  these  cases 
the  dietetic  treatment  plays  the  most  important  part  in  combating 
the  condition.  The  disturbances  caused  by  food  are  recognized 
by  the  general  symptoms :  vomiting,  rise  of  temperature,  sub- 
normal temperature,  and  the  stools,  the  latter  being  the  chief 
point  of  observation. 

Fats  as  Cause.  —  When  the  fats  are  causing  the  disturbance, 
the  rise  of  temperature  is  apt  to  be  high,  but  not  of  long  duration. 
The  baby  vomits  frequently,  the  vomitus  being  acid  in  reaction 
and  odor,  the  latter  due  to  the  presence  of  fatty  acids,  butyric 
acid,  etc.     Diarrhea  often  develops  in  a  more  or  less  acute  form. 


CARE  AND  FEEDING  OF  CHILDREN  193 

In  these  cases  there  is  a  loss  of  sodium  and  other  alkaline  salts  in 
the  feces,  and  a  consequent  excess  of  ammonia  in  the  urine,  result- 
ing in  acidosis.  Acid  intoxication  has  been  known  to  develop  as 
a  result  of  this  loss  of  alkaline  salts.  The  chief  symptoms  of  this 
condition  are  rapid  and  deep  respiration,  stupor  or  restlessness, 
and  cherry-red  lips.^ 

Symptoms  of  Excess  Fat  in  Diets.  —  The  general  symptoms  iii 
infants  receiving  an  excess  of  fat  in  their  food  take  the  form  of 
loss  of  appetite,  with  more  or  less  loss  of  weight,  or  failure  to  gain. 
When  the  cases  are  not  chronic,  soft  curds  may  often  be  seen,  which 
are  at  times  mistaken  for  casein  curds,  but  may  be  distinguished 
from  them  by  their  translucent  appearance  and  their  solubility  in 
ether.  The  color  of  the  stools  due  to  the  excess  of  fat  under  the 
above-mentioned  conditions  is  shiny  and  gray.  In  the  majority 
of  cases,  especially  of  a  more  chronic  character,  the  stools  are 
apt  to  be  large  and  dry,  at  times  hard  and  crumbly.  The  fat 
in  such  stools  is  combined  with  magnesium  and  calcium  salts, 
forming  the  characteristic  "  soap  stools."  ^  The  combined  loss 
of  these  salts  in  the  feces  has  a  definite  effect  on  the  general  me- 
tabolism and  nutrition,  giving  rise  to  rickets. 

Regulating  the  Fat.  —  The  treatment  consists  chiefly  of  regulat- 
ing the  amount  of  fat  in  the  formula,  and  of  cutting  it  out  altogether  •  • 
in  the  beginning  when  the  symptoms  show  acute  acid  conditions. 
In  many  cases,  if  the  baby  is  given  breast  milk,  the  trouble  dis- 
appears. At  other  times  it  is  necessary  to  substitute  a  foreign 
fat  such  as  olive  oil  for  the  butter  fat.  Dr.  Ladd  in  the  Children's 
Hospital  in  Boston  treated  many  babies  who  manifested  an  in- 
tolerance for  butter  fat  with  "  Homogenized  Milk,"  which  consisted 
of  skimmed  or  separated  milk  and  a  certain  percentage  of  olive 
oil,  placed  in  an  apparatus  which  brought  about  a  more  complete 
division  of  the  fat,  causing  it  to  mix  with  the  milk  as  an  emulsion 
closely  resembling  human  milk. 

Fat  intolerance  is  most  difficult  to  overcome,  the  baby  being  apt 
to  relapse  into  the  acute  stage  unless  the  utmost  caution  is  observed 

^  "Diseases  of  Nutrition  and  Infant  Feeding,"  by  Morse  and  Talbot. 
^Jbid. 


194  DIETETICS  FOR  NURSES 

in  adding  the  fats  to  the  formula.  It  is  not  safe,  however,  to  feed 
the  baby  upon  a  fat-free  milk  for  any  great  length  of  time. 

Excess  Protein  in  Food.  —  The  digestional  disturbances  arising 
from  too  much  protein  in  the  food  are  as  a  rule  readily  overcome  in 
breast-fed  infants.  When  it  is  due  to  nervousness  or  worry  in  the 
mother,  it  disappears  as  soon  as  the  mother  ceases  to  worry  or 
does  something  to  remove  the  cause  of  the  nervous  condition. 
When  the  breast  milk  is  high  in  protein,  more  exercise  in  the  open 
air  at  times  adjusts  the  percentage  of  protein,  providing  the 
mother  does  not  become  over-tired,  in  which  case  the  percentage  of 
protein  in  breast  milk  increases. 

Evidences  of  Excess  Protein.  —  The  s>Tnptoms  of  excess  protein 
in  the  diet  of  the  breast-fed  baby  are  colic  and  flatulence,  which  are 
often  persistent  and  difficult  to  overcome.  Vomiting  is  not  so 
common  in  these  babies  as  in  those  who  are  artificially  fed.  The 
stools  are  increased  in  number,  are  either  brown  or  green,  and 
generally  loose  and  watery.  In  artificially  fed  infants  the  symp- 
toms are  much  the  same,  except  that  the  vomitus  often  contains 
large  curds  which  are  tough  and  leathery.  The  baby  suffers  from 
gas  formation  and  colic.  The  stools  are  at  times  normal,  except 
for  the  presence  of  large,  hard  curds ;  at  other  times  they  are  in- 
creased in  number,  and  are  of  a  watery  consistency  and  alkaline 
in  reaction. 

Regulating  the  Protein  in  Formula.  —  When  the  stools  are 
watery  and  brown  and  musty  in  odor  as  the  result  of  disturbed 
protein  digestion,  the  treatment  consists  of  taking  out  the  proteins 
from  the  formula  and  of  substitutihg  cereal  water,  to  which  dextri- 
maltose  or  milk  sugar  is  added,  the  milk  being  added  as  soon  as 
possible  to  prevent  too  great  a  loss  of  body  protein.  As  a  rule  the 
whey  proteins  do  not  cause  the  disturbances  so  often  as  the  casein 
proteins ;  and  at  times  it  is  possible  to  use  whey  mixtures  with 
babies  who  cannot  tolerate  the  casein  at  all. 

Buttermilk  also  is  used  in  cases  of  protein  indigestion,  as  is 
Eiweissmilch  and  peptonized  milk. 

Regulating  the  Carbohydrates.  —  When  the  disturbances  are 
due  to  the  carbohydrates  in  the  formula,  they  may  be  digestional 


CARE  AND  FEEDING  OF  CHILDREN  195 

or  nutritional.  In  this  form  the  milk  sugar  is  more  apt  to  be  the 
cause  of  the  trouble  than  the  dextri-maltose  preparations  which 
are  at  times  used.  In  the  latter,  when  the  disturbance  becomes 
nutritional,  the  cause  of  the  trouble  can  usually  be  traced  to  an 
excess  of  starch.  When  the  percentage  of  milk  sugar  is  greater 
than  can  be  handled  by  the  digestive  apparatus  of  the  baby,  it  is 
manifested  by  frequent  attacks  of  colic,  with  the  passage  of  watery 
green  stools,  highly  irritating  in  character  on  account  of  their 
acidity.  In  acute  cases  the  loss  of  weight  is  often  marked,  and 
symptoms  of  intoxication  may  develop.  The  outlook  is  grave  in 
the  very  severe  cases,  but  if  the  baby  can  survive  forty-eight  hours 
after  the  acute  symptoms  develop,  he  is  apt  to  pull  through  the 
attack. 

Adjusting  the  Sugars.  —  The  treatment  in  these  conditions 
consists  of  eliminating  the  milk  sugar  from  the  formula;  in  less 
severe  cases  dextri-maltose  may  be  substituted.  As  a  rule,  coin- 
cident with  indigestion  caused  by  sugar  there  will  be  found  to  be 
an  intolerance  for  much  fat,  so  that  this  must  be  adjusted  as  well 
as  the  milk  sugar.  Skimmed  milk  mixtures,  containing  a  certain 
amount  of  barley  or  oatmeal  water,  are  generally  found  to  be  suit- 
able in  these  cases.  Dextri-maltose  may  be  added  after  a  few  days 
in  order  to  maintain  the  fuel  needs  of  the  body.  Eiweissmilch 
is  at  times  used,  but  whey  mixtures  are  contraindicated  on  account 
of  their  high  sugar  content. 

Dextri-maltose  also  disagrees  at  times.  The  baby  has  colic 
and  flatulence,  the  stools  are  usually  loose  or  watery  and  dark 
brown  in  color.  The  dietetic  treatment  consists  of  an  immediate 
withdrawal  of  the  dextri-maltose  preparation  and  a  substitution 
of  milk  sugar  after  a  few  days. 

Evidences  of  Excess  Starch  in  Formula.  —  The  disturbances 
arising  from  an  excess  of  starch  in  the  diet  are,  as  has  already  been 
stated,  more  apt  to  be  of  a  chronic  than  an  acute  character. 
Vomiting  is  not  a  common  symptom  under  these  conditions,  al- 
though colic  is  frequent.  The  stools  are  at  times  loose  and 
brown,  at  other  times  dry  and  small.  The  baby  at  times  suffers 
from  diarrhea  and  at  others  from  constipation.     When  the  dis- 


196  DIETETICS  FOR  NURSES 

turbance  is  acute  the  starch  must  be  entirely  eliminated  from  the 
formula.  If  proprietary  foods  are  being  used  containing  starch, 
whether  it  is  dextrinized  or  unchanged,  they  must  be  at  once 
abandoned,  and  a  formula  made  up  of  protein  with  sugar  and 
fat. 

Modified   Milk   Formulas   Suggested  by  Morse  and   Talbot  for 

These  Conditions 

Fat 1.00%  Fat 2.00% 

Milk  sugar       .     .     .     4.00%  or  Milk  sugar       .     .     .     5.00% 

Protein 0.75%  Protein        .     .     .     .     1.25% 

They  likewise  advise  whey  and  whey  mixtures  under  these  cir- 
cumstances. 

Fermentation.  —  Fermentation  is  often  the  cause  of  infantile 
indigestion.  At  times  it  is  acute  and  may  cause  a  decided  ele- 
vation of  temperature  owing  to  the  absorption  of  the  toxic  sub- 
stances formed  as  a  result  of  the  bacterial  action.  In  almost 
every  case  of  indigestion  brought  on  by  fermentation  there  will 
be  an  accompanying  diarrhea.  As  a  rule  the  carbohydrates  are 
more  liable  to  the  attacks  of  bacteria  in  the  stomach  than  the  other 
food  constituents. 

Treatment.  —  The  treatment  consists  first  of  starvation,  no 
food  being  given  for  at  least  twenty-four  hours.  Then  water  or 
weak  tea,  sweetened  with  saccharine,  may  be  given,  but  nothing 
else.  The  medical  treatment  must  be  left  to  the  discretion  of  the 
physician.  When  the  condition  warrants  a  return  to  food  the 
formula  must  be  made  weaker  than  that  which  has  caused  the 
disturbance.  Malt  soup  mixtures,  buttermilk  mixtures,  whey  and 
albumen  water  may  be  added  as  the  condition  of  the  baby  improves. 
In  older  children  the  period  of  starvation  may  have  to  exceed  that 
of  infants,  but  a  gradual  return  to  normal  diet  is  made.  Weak 
tea  and  toast  may  be  given  after  the  first  twenty-four  hours  and 
well  skimmed  meat  broths,  soft-cooked  eggs,  liquid  peptonoids, 
and  malted  milk  added  to  the  diet  as  the  condition  of  the  child 
improves. 


CARE  AND  FEEDING  OF  CHILDREN  197 

ENTEROCOLITIS 

The  dietetic  treatment  for  enterocolitis  must  be  adjusted 
according  to  the  principal  symptom.  In  some  of  these  cases  diar- 
rhea is  most  prominent,  while  in  others  constipation  is  the  most 
marked  symptom.  Hence  the  diet  must  be  such  as  not  only  to 
do  no  harm  to  the  child,  but  one  that  will  aid  in  his  ultimate 
recovery. 

DIARRHEA 

The  treatment  for  diarrhea,  whether  it  is  from  fermentation  or 
putrefaction  of  food,  has  already  been  explained.  The  grave  danger 
in  the  putrefactive  diarrhea  is  the  absorption  of  the  toxic  sub- 
stances which  result  from  bacterial  action  upon  the  unabsorbed 
food  material  in  the  small  and  large  intestine.  In  these  cases 
auto-intoxication  may  develop  and  the  baby  may  die  before  the 
condition  yields  to  treatment.  The  entire  intestine  must  be 
cleansed  as  a  rule.  The  stomach  of  the  baby  may  be  reached 
with  little  trouble  by  using  a  small  rubber  catheter  attached  to 
a  glass  funnel  and  a  solution  of  bicarbonate  of  soda.  The  bowels 
may  be  emptied  by  means  of  a  soapsuds  enema.  Older  children 
may  be  given  oil,  but  this  of  course  comes  under  the  jurisdiction 
of  the  physician. 

CONSTIPATION 

Constipation  is  one  of  the  most  frequent  troubles  visited  upon 
people  of  all  ages.  "  It  is  not  a  disease,  it  is  a  condition  in  which 
the  number  of  stools  is  less  or  the  consistency  of  the  stools  is  greater 
than  is  normal  for  the  individual  at  the  given  time."  ^  It  may  be 
caused  by  neglect  of  the  bowels,  which  should  be  evacuated  once 
or  twice  every  day  during  infancy  and  once  a  day  after  that  period. 
If  the  habit  of  emptying  the  bowels  every  day  is  established  in 
infancy  it  adds  much  to  the  health  and  comfort  of  the  individual 
during  the  entire  remainder  of  life.  Babies  are  sometimes  con- 
stipated as  the  result  of  the  opium  administered  in  soothing  sirups. 

3  "Diseases  of  Nutrition  and  Infant  Feeding,"  p.  307,  by  Morse  and  Talbot. 


198  DIETETICS  FOR  NURSES 

Others  inherit  constipation,  while  still  others  are  constipated  by 
the  taking  of  the  wrong  kind  of  food  or  too  little  food.  In  any  case 
it  is  decidedly  bad  to  resort  to  drugs,  since  the  habit  of  taking 
cathartics  is  so  easily  acquired  and  so  difficult  to  overcome. 

Factors  Inducing  Constipation.  —  With  artificially  fed  babies 
a  formula  which  contains  too  high  a  percentage  of  diluent  and  too 
low  a  percentage  of  solids  will  cause  constipation,  chiefly  because 
the  solids  are  so  completely  absorbed  that  they  have  no  residue  to 
form  feces.  A  formula  with  too  low  a  fat  content  in  proportion 
to  its  protein  and  carbohydrates  may  cause  constipation  because 
the  latter  two  constituents  are  almost  entirely  absorbed,  and  the 
feces,  which  is  largely  made  up  of  the  fat,  is  correspondingly  small. 
Excess  of  fat,  however,  has  been  proved  to  be  one  of  the  chief  causes 
of  constipation  in  infants,  as  has  also  been  the  case  with  excess 
starch.  Boiling  the  milk  for  the  baby  at  times  results  in  con- 
stipation. Hence  sterilization  is  more  frequently  to  blame  for 
the  condition  than  the  pasteurization  of  milk. 

Constipation  during  Second  Year.  —  During  the  second  year, 
if  the  child  is  given  too  much  milk  and  too  little  solid  food,  constipa- 
tion is  very  apt  to  be  the  result.  A  maximum  quantity  of  from 
thirty-two  to  forty  ounces  may  be  given.  In  many  diseases 
brought  on  by  malnutrition,  constipation  is  an  obstinate  condition 
to  be  overcome.    This  is  especially  the  case  in  rickets  and  anemia. 

Use  of  Laxative  Foods.  —  After  the  baby  is  a  few  months  old, 
orange  juice  is  given  between  the  morning  feedings.  Malted 
foods  likewise  exert  a  laxative  effect.  The  higher  the  percentage 
of  maltose,  the  more  laxative  the  food.  The  nurse  must  keep  this 
point  in  mind  in  feeding  babies.  With  older  children  and  adults, 
the  question  of  diet  for  constipation  is  quite  as  important  as  it 
is  for  infants.  Prunes  or  figs  cooked  with  senna  leaves  and  thor- 
oughly strained  furnish  an  excellent  adjunct  to  the  diet  under  such 
conditions.  The  coarse  breads  such  as  bran  and  Graham  or  whole- 
wheat bread  should  be  used  instead  of  white  flour  breads.  Care 
should  be  taken  in  advising  a  cereal  diet  for  children,  since  cereals, 
with  the  exception  of  oats,  are  apt  to  be  constipating.  Fresh  fruits, 
stewed  fruits,  and  fresh  vegetables  are  all  good  under  the  above- 


CARE  AND  FEEDING  OF  CHILDREN  199 

mentioned  conditions.  Young  children  require  the  vegetables 
strained  or  cut  fine.  Adults  should  include  one  coarse  vegetable  a 
day  in  their  dietary  to  obviate  the  development  of  constipation. 
Children  should  be  taught  to  drink  plenty  of  water,  and  babies 
should  not  be  neglected  in  this  respect.  As  a  rule,  very  few  adults 
drink  as  much  water  as  is  necessary  for  the  general  welfare  of  their 
bodies. 

RICKETS 

Rickets  is  a  constitutional  disease,  due  to  disturbed  nutrition, 
developing  in  infancy  and  early  childhood,  generally  between  the 
sixth  and  eighteenth  months.  The  exact  cause  of  this  disease  is 
still  unknown,  but  it  is  much  more  common  in  artificially  fed 
infants  than  those  receiving  breast  milk.  This  may  be  due  to  the 
fact  that  the  mineral  salts,  like  the  other  constituents,  are  com- 
bined in  the  mother's  milk  in  measures  which  meet  the  needs  of  the 
baby  more  efficiently  than  is  the  case  in  cow's  milk.  The  me- 
tabolism of  the  phosphorus  and  calcium  in  rickets  is  interfered 
with,  and  the  bones  of  babies  suffering  from  this  disease  show  a 
diminished  amount  of  calcium  and  phosphorus  and  an  increased 
amount  of  water.  As  the  disease  progresses  the  bones  bend  into 
deformities,  owing  to  the  lack  of  calcium,  which  gives  rigidity  and 
permanence  to  the  skeleton. 

Dietetic  Treatment.  —  The  treatment  of  rickets  is  essentially 
one  of  diet.  There  is  no  doubting  the  fact  that  good  breast  milk 
is  the  best  food  in  this  condition,  as  it  is  in  all  nutritional  dis- 
turbances, but  when  it  is  impossible  to  secure  it  for  the  baby,  the 
next  best  thing  is  a  properly  modified  milk  formula.  This  formula 
must  be  made  to  suit  the  digestive  capacity  of  the  individual  infant 
at  the  time.  It  is  believed,  however^  "  that  it  is  well  to  keep  the 
percentage  of  fat  lower  and  that  of  the  carbohydrates  higher  than 
would  ordinarily  be  done."  ^  This  is  probably  done  on  account  of 
the  effect  upon  the  retention  of  calcium  and  phosphorus  in  the 
body  of  the  infant,  exerted  by  the  different  food  constituents. 

*  "Diseases  of  Nutrition  and  Infant  Feeding,"  p.  324,  by  Morse  and  Talbot. 


200  DIETETICS  FOR  NURSES 

Calcium  in  the  Diet.  —  In  cow's  milk  the  calcium  content  is  in 
excess  of  the  needs  of  the  baby,  hence  there  is  no  reason  what- 
soever to  give  the  ricketic  baby  additional  calcium.  If  the  baby  is 
not  breast  fed  or  is  not  receiving  a  modified  cow's  milk,  then  he 
may  not  receive  sufficient  calcium  for  his  needs,  in  which  case  the 
diet  must  be  changed  to  one  or  the  other.  Care  must  be  observed 
not  to  give  too  rich  a  food,  since  in  this  way  the  baby's  ability  to 
handle  a  sufficient  amount  would  so  limit  the  calcium  intake  as 
to  make  it  insufficient. 

Excess  Fat  and  Calciiim  Retention.  —  As  has  already  been 
mentioned,  it  is  probable  that  an  excess  of  fat  in  the  food  may 
interfere  with  the  calcium  retention,  on  account  of  the  combining 
of  the  salts  and  the  fats  and  in  this  way  interfering  with  the 
absorption  of  the  former  substance. 

Fresh  air  and  plenty  of  sunshine  are  necessary  in  the  treatment 
of  rickets.  In  some  cases  where  anemia  is  pronounced,  it  is  found 
advisable  to  give  some  form  of  iron. 

SCURVY 

Scurvy,  like  rickets,  is  a  constitutional  disease,  due  to  a  dis- 
turbance of  the  nutrition,  but  the  disease,  while  often  associated 
with,  is  not  synonymous  with  rickets. 

Hemorrhages.  —  Scurvy  has  been  receiving  much  attention 
in  the  last  few  years.  Dr.  Alfred  Hess  and  his  associates  have 
been  making  exhaustive  investigations  to  determine  the  cause  of 
the  hemorrhages  which  are  characteristic  of  this  disease,  and 
believe  that  the  tendency  toward  hemorrhages  is  due  to  a  weakness 
of  the  walls  of  the  blood  vessels,  rather  than  to  a  change  in  the 
blood  itself. 

Factors  Inducing  Scurvy.  —  Consensus  of  opinion  proves  that 
scurvy  is  caused  by  errors  in  diet,  not  temporary  errors,  but 
errors  which  have  continued  over  an  appreciable  length  of  time. 
In  the  various  investigations  and  analyses  of  the  diets  of  a  vast 
number  of  cases  the  trouble  is  now  believed  to  be  due  to  a  lack  of 
some  essential  element  in  the  food,  and  not  to  any  foreign  element. 


CARE  AND  FEEDING   OF   CHILDREN  201 

Scurvy  in  Breast-fed  Babies.  —  Breast-fed  babies  occasionally 
develop  scurvy,  but  it  is  by  no  means  so  common  in  these  infants 
as  in  those  receiving  an  artificial  food,  whether  that  food  consists 
of  a  milk  formula  or  a  proprietary  food.  Science  has  proved 
that  while  the  heating  of  milk,  as  in  pasteurizing  and  sterilizing 
and  boiling,  may  be  one  of  the  causes  of  this  disease,  it  is  not  the 
only  one,  since  babies  receiving  raw  milk  likewise  develop  scurvy. 

Lack  of  Vitamines.  —  Recently  it  has  come  to  be  believed  that 
possibly  the  lack  of  vitamines  in  diet  may  give  rise  to  this  trouble. 
These  substances  are  extremely  sensitive  to  heat,  and  when  babies 
are  fed  upon  cooked  milk  and  do  not  receive  other  food  in  which 
the  vitamines  are  not  destroyed  by  heat,  they  are  apt  to  develop 
scurvy.  It  has  been  known  for  a  long  time  that  fresh  fruit  juices 
and  vegetables  contain  antiscorbutic  elements,  and  for  this 
reason  they  have  been  included  in  the  diet  of  children  and  adults 
who  are  suffering  from  scurvy. 

Treatment.  —  If  the  baby  is  fed  on  breast  milk,  the  diet  of  the 
mother  should  be  changed  to  increase  the  nutrients  in  the  milk. 
When  proprietary  foods  are  used  they  should  either  be  made  up 
with  milk  or  should  be  eliminated  in  favor  of  a  modified  milk 
formula.  The  latter  should  be  pasteurized  when  necessary,  but 
as  low  a  degree  of  heat  used  as  possible  to  bring  about  the  desired 
result.  Orange  juice  is  the  simplest  and  most  available  of  sub- 
stances containing  the  necessary  properties  by  which  scurvy  is 
relieved.  This  may  be  added  to  the  diet  after  the  baby  is  a  few 
months  old,  the  dose  being  one  ounce  per  day,  given  one  hour 
before  the  milk  feeding  when  the  stomach  is  more  or  less  empty. 
It  may  be  diluted  with  water  and  slightly  sweetened  if  the  baby 
will  take  it  better  so.  Doctor  Hess  has  found  that  orange  peel 
also  contains  the  antiscorbutic  properties  and  has  the  advantage 
of  being  cheaper  than  oranges.^ 

Antiscorbutic  Foods.  —  Since  scurvy  yields  readily  to  the 
action  of  the  antiscorbutic  properties  in  orange  and  lemon  juice, 
it  is  not  necessary  to  give  vegetables  to  babies.     However,  in 

^  A  decoction  made  from  orange  peel  and  water  is  given  to  infants  having  incipient 
scurvy  in  the  Hebrew  Asylum,  New  York  City. 


202  DIETETICS  FOR  NURSES 

certain  cases  a  boiled  or  baked  Irish  potato  finely  mashed  and  given 
in  doses  of  one  to  two  tablespoonfuls  a  day  results  in  a  rapid  re- 
covery. Doctor  Hess  likewise  has  suggested  the  use  of  potato 
water  instead  of  cereal  diluents  in  the  preparation  of  infant  foods.  ^ 

Malnutrition  is  not  confined  to  the  children  of  the  poor,  though 
it  is  more  common  with  infants  of  parents  who  have  not  the  means 
to  secure  the  best  milk  and  give  them  the  benefit  of  wholesome 
surroundings  and  plenty  of  sunshine.  But  babies  of  people  in 
moderate  circumstances,  and  even  of  wealthy  parentage,  are  at 
times  badly  nourished,  and  require  the  same  exacting  care,  the 
same  attention  to  the  food,  the  fresh  air,  and  the  sunshine  that  the 
poorer  babies  need  in  order  to  survive.  Malnutrition  may  be  the 
result  of  insufficient  food,  and  it  may  also  be  due  to  the  lack  of  one 
definite  food  element.  Again,  it  may  be  brought  on  by  some  de- 
formity of  the  mouth  or  stomach,  which  makes  it  impossible  for 
the  baby  to  get  all  the  food  which  he  requires  for  his  maintenance 
and  growth.  He  may  be  born  prematurely  and  his  digestive 
apparatus  not  be  sufficiently  developed  to  care  for  the  amount  or 
type  of  food  necessary  for  his  needs,  or  he  may  have  some  congenital 
weakness  which  interferes  with  the  absorption  and  assimilation  of 
his  food.     All  of  these  points  must  be  considered. 

Evidences  of  Correct  Feeding.  —  If  the  baby  shows  a  steady 
gain,  both  in  weight  and  growth  of  stature,  without  digestional 
disturbances,  the  food  given  him  is  probably  correct,  but  it  must 
be  kept  in  mind  that  nutritional  disturbances,  such  as  rickets  and 
scurvy,  are  slow  in  developing,  and  do  not  manifest  themselves 
with  anything  like  the  rapidity  of  digestional  disturbances.  Hence 
the  nurse  must  take  care  as  far  as  she  is  able,  not  only  to  prevent 
the  food  from  causing  indigestion,  but  also  to  see  that  it  is  not 
given  in  such  a  form  as  to  induce  those  graver  and  more  lasting 
nutritional  disturbances  which  affect  the  entire  system  from 
infancy  throughout  the  life  of  the  individual. 

Summarizing  the  results  of  errors  in  the  diet  of  infants,  we  find 
that  they  are  both  acute  and  chronic  in  character,  and  that  they 
result,  not  only  in  digestional  disturbances,  but  in  the  more  grave 

fi  "American  Journal  Diseases  of  Children,"  1914,  VIII,  385,  by  Hess  and  Fish. 


CARE  AND  FEEDING  OF  CHILDREN  203 

disorders  which  affect  the  metabolism  and  general  nutrition  of  the 
infant.  The  acute  disorders,  such  as  acute  gastro-intestinal  in- 
digestion, brought  on  by  over-feeding,  may  cause  death  by  their 
very  violence,  the  infant  succumbing  to  the  exhaustion  which  is 
one  of  the  results  in  severe  attacks.  If,  however,  he  survives  the 
first  forty-eight  hours  after  the  beginning  of  the  acute  symptoms, 
the  chances  are  good  for  recovery. 

Relapse.  —  One  danger  which  the  nurse  must  always  be  on  the 
lookout  for  is  the  relapse  into  the  acute  stage.  The  diet  is  the 
chief  treatment.  In  acute  gastro-intestinal  disturbances  rest 
from  food  is  essential  for  at  least  twenty-four  hours.  Some  infants 
can  easily  endure  starvation  for  this  short  period.  However, 
when  malnutrition  has  already  been  established,  it  is  not  wise  to 
carry  out  the  starvation  treatment  over-long.  A  cautious  return 
to  a  normal  diet  may  be  made  as  soon  as  acute  symptoms  dis- 
appear. In  many  conditions  of  disturbed  digestion  it  is  not  wise 
to  use  cow's  milk  unless  it  is  predigested,  and  at  times  even  this 
treatment  does  not  render  it  a  safe  food.  In  these  cases  it  has 
been  found  necessary  to  use  whey  mixtures,  cereal  waters,  and 
albumen  water  until  the  baby  can  once  more  digest  his  regular 
formula.  Before  giving  the  latter  it  must  be  remembered  that 
the  digestive  apparatus  has  lost  to  a  certain  degree  its  capacity  to 
handle  the  formula  suitable  to  the  age  and  weight  of  the  infant,  so 
that  one  suitable  for  a  much  younger  child  must  be  used  and 
gradually  strengthened  until  the  original  formula  is  tolerated. 
It  has  been  proved  that  many  infants  who  have  suffered  from  an 
excess  of  milk  sugar  in  their  food  have  an  intolerance  for  this  sugar 
lasting  for  months  and  even  years.  These  babies  need  other 
sugars  to  replace  this  necessary  constituent  in  their  diet. 

SUMMARY 

Breast  Feeding  versus  Artificial  Feeding.  —  There  is  no  doubt 
about  the  fact  that  the  breast-fed  baby  suffers  less  from  diges- 
tional  disturbances  and  has  more  resistance  to  disease  than  the 
baby  fed  even  upon  a  perfectly  prepared  artificial  food.     Hence 


204  DIETETICS  FOR  NURSES 

every  effort  must  be  made  by  the  nurse  to  assure  a  sufficient 
secretion  of  milk  in  the  mother. 

Errors  in  Diet  cause  the  majority  of  disturbances  in  the 
artificially  fed  baby.  Too  much  or  too  little  food,  badly  balanced 
formulas,  too  high  or  too  low  a  proportion  of  diluent  to  meet  the 
needs  of  the  individual,  unclean  or  impure  milk,  or  the  improper 
preparation  of  the  formula,  all  lead  to  gastro-intestinal  disturb- 
ances and,  if  persisted  in,  will  undoubtedly  lead  to  disorders  of 
a  much  more  serious  and  lasting  character.  Gastro-intestinal 
disturbances,  colitis,  enterocolitis,  rickets,  scurvy,  diabetes,  and 
nephritis  are  among  the  diseases  traceable  to  injudicious 
feeding. 

Overfeeding  probably  causes  more  of  the  acute  diseases 
than  underfeeding.  Most  of  the  gastro-intestinal  disorders  can 
be  readily  traced  to  the  giving  of  too  much  food  or  too  strong 
a  formula.  These  diseases  usually  yield  to  a  change  in  the  dietary 
or  a  period  of  starvation  to  allow  time  for  the  digestive  tract 
to  adjust  itself  and  the  surplus  food  to  pass  out  of  the  body,  this 
treatment  to  be  followed  by  a  weaker  formula,  with  longer  intervals 
between  feedings  and  small  quantities  at  each  feeding. 

Underfeeding  not  only  means  too  little  food,  but  also  covers 
the  unbalanced  formulas.  A  baby  may  be  receiving  too  little  of 
the  necessary  food  constituents  for  his  body  requirements.  The 
quantity  may  be  made  up  in  dilution,  causing  the  infant  to  receive 
a  sufficient  amount  of  fluid  at  a  feeding,  but  in  so  diluted  a  form  as 
to  be  entirely  inadequate  for  his  needs.  In  this  case  his  appetite 
is  satisfied  but  the  material  for  the  growth,  development,  and 
energy  expenditures  is  lacking,  hence  his  body  suffers. 

Unbalanced  Diet.  —  Excess  fat,  carbohydrate,  or  protein,  as 
well  as  too  little  of  any  of  these  food  constituents,  results  in 
digestive  and  nutritional  disorders,  both  mild  or  grave  in  char- 
acter and  both  acute  or  chronic  in  form  according  to  the  extent 
and  duration  of  the  dietetic  error. 

Evidences  of  an  Unbalanced  Diet.  —  The  infant  is  fretful, 
sleeps  badly,  loses  appetite,  fails  to  gain  normally,  loses  weight, 
vomits  more  or  less  frequently,  develops  diarrhea,  has  a  rise  in 


CARE  AND  FEEDING  OF  CHILDREN  205 

temperature,  shows  symptoms  of  intoxication  and  changes  in  the 
bony  structure  of  his  body. 

Acute  Digestive  Disorders,  on  account  of  their  acute  char- 
acter, are  quickly  recognized  and  most  frequently  yield  to  treat- 
ment. A  change  in  the  character  or  quantity  of  the  food,  preceded 
by  a  period  of  starvation,  as  a  rule  brings  about  the  desired  result. 

Chronic  Nutritional  Disorders,  such  as  rickets,  are  more  diffi- 
cult to  handle,  less  easy  to  recognize,  and  consequently  more 
grave  in  results.  Early  diagnosis  and  prompt  treatment  by  diet 
may  arrest  the  disease  and  effect  a  cure  unless  there  is  a  deforma- 
tion of  the  bones. 

The'  Stools,  in  all  infantile  disturbances,  furnish  the  chief 
point  of  investigation,  giving  a  fair  idea  of  the  processes  taking 
place  in  the  infant  organism.  A  study  of  the  stools  sometimes 
shows  abnormal  characteristics  therein  and  goes,  far  towards 
enabling  the  nurse  to  prevent  the  gastro-intestinal  disorders  from 
making  great  headway  and  the  disease  from  becoming  chronic. 

Too  Much  Protein  in  Diet.  —  Stools  are  either  brown  or  green 
in  color,  large  and  watery  in  character,  frequent  in  number  and 
alkaline  in  reaction,  showing  the  presence  of  large,  hard  curds,  or 
they  are  normal  except  for  the  presence  of  such  curds. 

Too  Much  Fat  in  Diet.  —  Stools  show  the  presence  of  soft  curds, 
which  are  sometimes  mistaken  for  casein  curds  but  may  be  dis- 
tinguished from  them  by  their  translucent  color  and  solubility 
in  ether.  The  stools  themselves  are  shiny  and  gray,  large,  dry,  and 
at  times  crumbly  in  character,  especially  in  chronic  conditions 
due  to  excess  fat  in  the  diet. 

Soap  Stools  is  the  name  given  to  those  in  which  the  fats 
are  combined  with  magnesium  and  calcium  salts,  the  salts  thus 
lost  in  the  feces  giving  rise  to  nutritional  disturbances  which  at 
times  result  in  rickets. 

Excess  Carbohydrate.  —  Too  much  sugar  (lactose)  results  in 
stools  watery  and  green  in  color  and  highly  irritating  in  character 
on  account  of  their  acidity. 

Dextri-maltose.  —  An  excess  of  this  sugar  in  diet  gives  rise  to 
watery,  dark  brown  stools. 


206  DIETETICS  FOR  NURSES 

Excess  Starch.  —  Stools  at  times  are  loose  and  brown,  at  others 
dry  and  small.  Diarrhea  is  the  result  of  too  much  starch  in  the 
diet,  while  in  other  cases  constipation  results  from  a  like  condition. 

Fermentation  is  often  the  cause  of  infantile  disorders.  It 
may  cause  an  elevation  of  temperature  owing  to  the  absorption 
of  toxic  substances  produced  as  the  result  of  bacterial  action. 
The  attacks  of  indigestion  (colic  and  stomach,  etc.)  are  frequently 
accompanied  by  diarrhea.  The  carbohydrates,  sugar  in  particular, 
are  more  subject  to  the  action  of  bacteria  in  the  stomach  than  the 
other  food  constituents. 

Dietetic  Treatment :  Starvation.  —  No  food  for  twenty-four 
hours  —  water  or  weak  tea  sweetened  with  saccharine  may  be 
given,  nothing  else.  As  acute  symptoms  disappear  and  condi- 
tions improve,  a  modified  milk  formula,  weaker  than  the  one  used 
before  the  attack,  may  be  given.  The  strength  of  the  mixture 
may  be  increased  as  the  infant  improves,  taking  care  to  make 
the  changes  in  strength  gradually.  Malt  soup  mixtures,  but- 
termilk, whey  mixtures,  and  albumen  water  may  be  used  in  place 
of  the  milk  formula,  if  that  disagrees.  In  older  children  the  star- 
vation period  may  be  extended  slightly,  if  necessary,  or  weak  tea 
and  toast  given  after  twenty-four  hours.  The  diet  is  increased 
by  adding  well-skimmed  broths,  soft  eggs,  malted  milk,  or  liquid 
peptonoids  as  the  patient  improves. 

Enterocolitis  may  have  diarrhea  or  constipation  as  chief  symp- 
toms, and  dietetic  treatment  must  be  adjusted  to  meet  the 
needs  of  the  individual  according  to  the  development  of  the 
symptoms. 

Diarrhea.  —  When  fermentation  causes  the  diarrhea,  the  logical 
treatment  is  to  remove  the  source  of  fermentation  and  adjust  the 
diet  as  already  described.  When  putrefaction  is  the  cause,  the 
patient  may  suffer  from  auto-intoxication  as  the  result  of  the 
absorption  of  the  toxic  substances  produced  by  bacterial  action 
upon  unabsorbed  food  material.  Treatment  consists  in  cleansing 
the  bowels  to  rid  them  of  any  putrefied  food  material,  and  changing 
the  formula.  Buttermilk  mixtures  are  particularly  good  under  the 
circumstances. 


CARE  AND  FEEDING   OF  CHILDREN  207 

Constipation  in  infants  results  most  often  from  too  high  a 
percentage  of  diluents  and  too  low  a  percentage  of  solids.  A 
deficiency  in  the  fat  content  in  proportion  to  the  protein  and  car- 
bohydrates in  a  formula  will  also  cause  constipation.  On  the  other 
hand,  an  excess  of  fat  has  proved  one  of  the  most  frequent  causes 
of  constipation.  Excess  starch  is  another  cause  of  this  disorder 
in  babies. 

Constipation  in  Older  Children  is  often  brought  on  as  the 
result  of  insufficient  solid  food  and  too  much  milk  in  the  diet. 
Thirty-two  to  forty  ounces  a  day  is  the  maximum  quantity  of  milk 
allowable  during  the  second  year. 

Treatment.  —  Malted  foods  exert  a  laxative  effect  and  can  be 
used  with  good  results  for  babies.  After  a  few  months,  orange 
juice  may  be  given  between  the  morning  feedings  and  does  much 
to  overcome  this  condition.  With  older  children  coarse  breads, 
prunes  and  figs  cooked  with  senna  leaves,  fresh  fruits,  and  green 
vegetables  all  exert  a  stimulating  effect  upon  the  peristaltic  move- 
ments of  the  intestines  and  tend  to  overcome  the  constipation. 
Cereal  foods,  except  oats,  are  apt  to  constipate  children,  hence 
should  be  given  with  care  to  children  inclined  that  way. 

KICKETS 

Dietetic  Treatment.  —  Good  breast  milk  is  undoubtedly  best  for 
babies.  When  this  is  not  obtainable,  a  good  milk  formula,  in  which 
the  fats  are  kept  low  and  the  carbohydrates  correspondingly  higher 
than  under  ordinary  circumstances,  should  be  used.  Fresh  air 
and  sunshine  are  necessary  adjuncts  to  the  treatment  of  rickets. 

SCURVY 

Errors  in  Diet  probably  give  rise  to  this  condition.  These 
are  not  temporary  in  character  but  long-standing.  It  is  believed 
that  the  disease  develops  as  the  result  of  an  insufficiency  in  some 
essential  element  and  not  from  the  presence  of  some  foreign 
element. 

Breast-fed  Babies  are  less  apt  to  develop  scurvy  than  artificially 
fed  infants. 


208  DIETETICS  FOR  NURSES 

Pasteurized  or  Sterilized  Milk  may  cause  some  of  the  cases, 
but  by  no  means  all  of  them,  since  babies  fed  upon  raw  milk 
have  been  known  to  develop  scurvy. 

Vitamines.  —  The  lack  of  vitamines  in  the  diet  has  also  been 
advanced  as  a  cause  of  this  disease.  Heat  destroys  the  vita- 
mines and  this  may  be  the  reason  for  not  pasteurizing  or  steri- 
lizing the  milk  for  babies  having  scurvy. 

Treatment.  —  The  diet  of  the  mother  of  the  breast-fed  baby  with 
scurvy  must  be  changed  to  increase  its  nutrient  qualities.  Arti- 
ficially fed  infants,  if  taking  proprietary  infant  foods,  should  have 
them  made  up  with  milk  instead  of  water  or  eliminated  entirely 
in  favor  of  a  suitable  milk  formula,  pasteurized,  if  necessary,  at 
a  low  degree  of  heat. 

Orange  Juice  is  the  simplest,  the  best  known,  and  the  most 
available  substance  which  can  be  used  to  overcome  scurvy.  It 
may  be  added  to  the  diet  of  an  infant  a  few  months  old  as  well  as 
to  that  of  older  children.  .  A  decoction  of  orange  peel  and  water 
exerts  a  similar  antiscorbutic  effect  and  may  be  used  in  con- 
junction with  the  orange  juice,  thus  lessening  the  cost  of  the 
treatment. 

Antiscorbutic  Foods.  —  Orange  and  lemon  juice,  vegetables 
(especially  Irish  potato) .  The  water  in  which  potatoes  are  boiled 
has  been  suggested  as  a  diluent  to  replace  the  cereal  waters. 


CHAPTER  XII 

FEEDING    IN    INFECTIOUS    DISEASES    OF    INFANCY 
AND  CHILDHOOD 

Fevers  in  General.  —  It  requires  very  little  deviation  from  the 
normal  to  raise  the  temperature  of  a  child.  A  slight  attack  of 
indigestion,  a  slight  soreness  of  the  throat,  will  bring  up  the  tem- 
perature of  some  children  out  of  all  proportion  to  the  seriousness  of 
the  disorder. 

Diet  in  Fevers  of  Short  Duration.  —  As  a  rule,  in  the  fevers  of 
short  duration,  such  as  intermittent  fever,  malarial  fever,  etc.,  the 
diet  is  a  simple  matter.  Milk  is  given  when  it  agrees,  with  butter- 
milk, koumiss,  broths,  and  albumenized  beverages  to  vary  the  diet. 

Diet  in  Infectious  Diseases.  —  When,  however,  the  fever  is 
induced  by  specific  bacteria,  such  as  in  the  case  of  typhoid  and 
scarlet  fever,  the  diet  is  a  different  matter  altogether.  The  dis- 
ease may  be  one  in  which  the  diet  is  the  chief  item  of  importance  ; 
such  is  the  case  with  typhoid  and  scarlet  fever,  with  the  former 
because  of  its  long  duration,  the  increased  rate  of  metabolism  due 
to  both  the  fever  and  the  action  of  the  bacteria  making  it  necessary 
to  increase  the  normal  amount  of  food  to  meet  the  new  require- 
ments of  the  body ;  and  with  the  latter  on  account  of  the  kidney 
complications  which  must  be  guarded  against,  and  which  can  only 
be  handled  by  regulating  the  diet. 

Infant  Feeding.  —  The  feeding  of  infants  under  febrile  condi- 
tions resolves  itself  into  an  adjustment  of  the  milk  formula  to 
meet  the  existing  state  of  affairs.  The  digestion  is  always  more  or 
less  disturbed  by  fever,  especially  during  the  early  stages. 

Restricting  the  Food,  —  It  is  not  always  possible  to  diagnose  the 

disease  immediately,  so  that  the  safe  thing  to  do  is  to  lengthen  the 

intervals  between  the  feedings  for  the  breast-fed  baby  and  to  stop 

food  entirely  for  twelve  to  twenty-four  hours  for  those  who  are 

p  209 


210  DIETETICS  FOR  NURSES 

artificially  fed,  when  there  is  any  doubt  as  to  the  cause  of  the  rise 
of  temperature.  Some  mothers  find  it  difiicult,  if  not  impossible, 
to  institute  this  period  of  starvation.  In  these  cases  barley  water 
or  albumen  water  may  be  given  at  stated  intervals.  Many 
physicians  give  very  weak  tea,  slightly  sweetened,  under  the 
above  conditions ;  it  does  no  harm  to  the  baby  and  relieves  the 
mother  from  the  belief  that  her  child  is  being  starved  to  death. 
In  twenty-four  hours,  if  the  fever  arises  from  disturbed  digestion, 
some  manifestation  of  the  condition  will  be  observed. 

Bacterial  Activity.  —  In  cases  of  intestinal  putrefaction  the 
fever  is  apt  to  rise  at  an  alarming  rate  and  as  controlled  only  by 
removing  the  cause.  The  proteins  which  have  escaped  digestion 
and  absorption  in  the  intestines  furnish  the  best  medium  for  the 
growth  of  putrefactive  bacteria.  Hence  this  food  constituent 
must  be  given  in  its  most  digestible  form. 

Dietetic  Treatment.  —  Milk  in  most  instances  is  the  best  form 
in  which  to  give  protein  food,  especially  to  young  children  and 
babies.  At  times,  however,  it  will  be  found  that  milk  disagrees ; 
it  must  be  peptonized,  or  one  of  the  fermented  milks,  such  as  but- 
termilk (Bulgarian  culture),  Eiweissmilch,  or  koumiss  must  be 
substituted.  In  cases  where  the  putrefactive  bacteria  make  it 
unwise  to  use  milk  at  all,  for  a  time  the  proteins  should  be  furnished 
in  the  form  of  cereal  gruels,  and  the  juice  of  an  orange  strained 
and  diluted  given  once  or  twice  a  day  between  the  morning  and 
evening  feedings. 

Whey  is  contraindicated  in  cases  where  the  fever  is  brought  on 
by  putrefaction  in  the  intestine,  chiefly  because  it  furnishes  one  of 
the  best  mediums  known  for  the  growth  of  the  offending  bacteria. 

Patience  is  required  in  handling  the  diet  for  fevers  in  infancy. 
As  has  already  been  stated,  it  requires  a  very  slight  cause  to  raise 
the  temperature  of  a  child,  but  for  this  very  reason  especial  care 
must  be  observed  that  no  enlightening  symptom  escapes  the  notice 
of  the  nurse. 

Complications.  —  Tuberculosis  or  scurvy  may  be  in  an  incipient 
stage,  and  may  be  overcome  if  recognized  in  time.  The  nurse  has 
a  better  opportunity  for  observing  changes  in  an  infant  or  child 


FEEDING  IN  INFECTIOUS  CONDITIONS        211 

under  her  care  than  the  physician  who  comes  once  a  day  or  less. 
The  nurse  should  make  note  of  these  changes,  that  the  physician 
may  have  a  chance  to  regulate  the  diet  accordingly. 

Fluid  Diet.  —  With  children,  as  with  adults,  the  energy  output 
in  fever  is  greater  than  in  health,  hence  the  need  for  plenty  of 
fluids  to  help  eliminate  the  waste  products  due  to  the  increased 
metabolism.  These  fluids  may  consist  of  water,  fruit  beverages, 
cereal  water,  whey,  and  broth.  It  is  well  for  the  nurse  to  remember 
that  when  the  child  is  confined  to  bed,  he  will  not  need  so  much 
food  as  he  would  if  he  were  up  and  about,  but  that  if  the  fever  is 
of  long  duration,  as  in  typhoid,  the  increased  rate  of  metabolism 
must  be  met  by  an  increased  amount  of  food,  as  the  ordinary  re- 
quirement standards  for  a  child  in  health  cannot  be  applied  to  the 
diet  of  a  child  under  these  conditions. 

SCARLET   FEVER 

Scarlet  fever  is  an  acute  infectious  disease,  characterized  by  high 
fever,  sore  throat,  a  red  rash,  and  a  tendency  to  nephritis.  The 
disease  usually  begins  suddenly  with  an  attack  of  vomiting ;  the 
temperature  rises  to  104°  or  105°  and  on  the  first  or  second  day  a 
rash  appears,  first  on  the  chest  and  neck,  and  spreads  over  the 
entire  body.  This  lasts  from  three  to  seven  days,  desquamation 
begins  soon  after  the  rash  disappears  and  lasts  from  two  weeks  to 
six,  the  palms  of  the  hands  and  soles  of  the  feet  peeling  last.  The 
appearance  of  the  tongue  is  very  characteristic,  being  coated,  and 
through  this  coating  are  seen  a  few  bright  red  points,  producing 
the  well-known  strawberry  tongue.  After  a  few  days  the  coating 
disappears,  leaving  the  tongue  bright  red.  In  mild  cases  the 
tonsils  are  enlarged  and  the  throat  very  red.  In  severe  cases  there 
may  be  difficulty  in  distinguishing  the  disease  from  diphtheria 
without  a  culture  being  taken.  The  tendency  of  the  child  to  de- 
velop nephritis  during  the  second  or  third  week  makes  the  treat- 
ment largely  dietexic  in  character. 

Dietetic  Treatment.  — Milk  is  the  chief  diet  for  the  first  three 
weeks.  If  it  disagrees,  it  should  be  modified  or  peptonized  to 
suit  the  condition.     Koumiss  and  buttermilk  may  be  substituted 


212  DIETETICS  FOR  NURSES 

when  it  is  impossible  to  prepare  the  milk  so  that  it  will  not  cause 
digestional  disturbances.  This,  however,  is  seldom  found  to  be  the 
case  during  infancy.  Malted  milk  and  even  condensed  milk,  or 
some  of  the  dextrinized  and  malted  foods  at  times  prove  valuable 
when  whole  milk  disagrees.  But  the  nurse  must  remember  that 
a  baby  runs  a  risk  of  developing  nutritional  diseases  of  a  grave 
character  if  fresh  milk  is  eliminated  from  the  diet  for  any  great 
length  of  time. 

Older  children  may  have  plain  vanilla  ice  cream  and  plain 
junket,  oyster  or  clam  broth  made  with  milk,  the  oysters  and 
clams  carefully  strained  out.  Lemonade  and  orange  juice  may  be 
given,  but  no  meat  broths  or  albumenized  beverages  or  egg  dishes 
can  be  admitted  to  the  dietary. 

Development  of  Nephritis.  —  Nephritis  must  be  guarded  against. 
The  skin,  being  covered  with  a  rash,  is  put  out  of  commission  as 
an  excretory  organ ;  in  consequence  all  of  the  work  of  this  de- 
scription is  placed  upon  the  kidneys.  In  the  first  part  of  this 
text  the  work  of  the  kidneys  was  defined ;  it  was  found  that  they 
were  the  chief  organs  for  the  excretion  of  the  end-products  of  pro- 
tein metabolism.  It  can  be  readily  understood  that  when  these 
organs  are  given  not  only  their  own  work  but  that  of  the  other 
organs  to  perform,  unless  the  food  requiring  the  greatest  amount 
of  effort  on  the  part  of  the  kidneys  is  confined  to  those  types  which 
can  be  most  easily  taken  care  of,  such  as  milk,  the  kidneys  stand  a 
great  chance  of  becoming  impaired.     Such  is  the  case  in  nephritis. 

Convalescent  Treatment.  —  The  return  to  normal  diet  must 
be  made  with  the  greatest  caution.  Specimens  of  urine  must  be 
taken  often,  for  in  this  way  alone  can  the  development  Of  nephritis 
be  reckoned  with.^  Should  nephritis  develop  in  spite  of  efforts 
to  prevent  it,  a  farinaceous  diet  ^  such  as  is  given  in  these  condi- 
tions must  be  resorted  to. 

After  three  weeks,  if  the  pateint  shows  no  disposition  toward 
nephritis,  and  if  convalescence  is  progressing  satisfactorily,  the 
diet  may  be  increased  day  by  day,  adding  milk  toast,  cereals, 

1  See  chapter  on  Urinalysis,  p.  298. 

'  Consisting  of  cereal  gruels,  rice,  and  other  starchy  foods. 


FEEDING  IN  INFECTIOUS  CONDITIONS        213 

cream  soups,  rice,  baked  potato,  then  custards  and  soft  eggs,  the 
soft  part  of  oysters,  broiled  or  baked  fish,  broiled  breast  of  chicken, 
and,  still  later,  rare  beef  and  lamb  chops.  Meat,  however,  must 
not  be  given  until  all  danger  from  nephritis  has  passed. 

DIPHTHERIA 

Diphtheria.  —  The  feeding  in  diphtheria  follows  the  regime  given 
in  acute  fevers.  The  body  must  be  kept  in  good  condition.  At 
the  same  time  it  is  necessary  to  understand  the  complications  which 
make  the  dietetic  treatment  of  this  disease  assume  a  place  of  im- 
portance. 

Complications.  —  It  may  be  complicated  by  broncho-pneu- 
monia, albuminuria,  carditis,  endocarditis,  and  dilation  of  the 
heart.  Anemia  must  be  combated,  but  care  should  be  used  not 
to  push  the  diet  to  such  an  extent  as  to  impose  too  great  a  tax 
upon  the  already  weakened  heart. 

Dietetic  Treatment.  —  While  the  fever  lasts  the  diet  must  be 
fluid,  milk,  buttermilk,  malted  milk,  and  some  of  the  proprietary 
infant  foods  such  as  Mellin's  Food,  Eskay's  Food,  and  like  prepa- 
rations. Milk  gruels,  made  with  milk  and  some  cereal  such  as 
farina,  barley  flour,  fine  cornmeal,  arrowroot,  strained  oatmeal, 
etc.,  are  at  times  more  easily  swallowed  than  the  unthickened 
liquids.  Liquid  beef  peptonoids,  panopeptone,  and  like  predi- 
gested  beef  preparations  prove  valuable  in  many  cases » 

Convalescent  Diet.  —  As  convalescence  progresses,  or  in  cases 
where  the  patient  finds  it  easier  to  swallow  a  semi-solid  than  a 
liquid,  soft  custards,  gelatine,  well-cooked  cereals,  and  ice  cream 
may  be  given.  Eggnog  and  milk  punch  are  at  times  given,  but 
only  upon  the  advice  of  the  physician  in  charge. 

Rectal  Feeding.  —  When  the  condition  of  the  patient  makes  it 
necessary  to  nourish  in  other  ways  than  by  mouth,  nutrient 
enemas  ^  may  be  given.  In  certain  cases  of  diphtheria,  young 
infants  can  be  fed  more  successfully  through  a  tube  inserted  by 
way  of  the  nose  into  the  stomach  than  by  feeding  in  the  ordinary 
way.    The  formula  is  prepared  in  the  same  way  as  for  bottle  feed- 

3  See  Nutrient  Enemas,  p.  143, 


214  DIETETICS  FOR  NURSES 

ing,  and  is  poured  into  a  glass  funnel  and  through  the  soft  rubber 
catheter  into  the  stomach.  Care  must  be  observed  to  prevent  the 
patient  struggling  on  account  of  the  heart  weakness  which  invari- 
ably complicates  this  disease. 

WHOOPING  COUGH 

In  the  early  months  of  life  it  is  probable  that  whooping  cough 
is  one  of,  if  not  the  most  fatal  of  the  diseases  to  which  the  infant 
is  subjected.  The  period  of  incubation  of  this  disease  is  from  one 
to  two  weeks,  the  cough  at  first  not  appearing  different  from  those 
accompanying  colds  of  all  sorts.  However,  in  from  ten  days  to 
two  weeks  the  characteristic  whoop  occurs,  differentiating  this 
disease  from  all  others.  The  symptoms  aside  from  the  whoop  are 
the  difficulty  of  taking  breath  and  the  great  prostration  after  the 
paroxysm  and  the  frequent  vomiting  of  the  food,  brought  on  by 
the  violent  coughing. 

In  very  young  infants  the  whoop  does  not  always  occur.  But 
the  child  coughs  and  holds  its  breath  until  it  is  blue  in  the  face. 
At  times  young  babies  may  have  convulsions.  The  so-called 
spasmodic  stage,  during  which  the  child  may  have  from  a  few  to  a 
great  number  of  paroxysms  of  coughing  a  day,  lasts  from  a  month 
to  six  weeks,  and  in  some  cases  even  longer.  As  the  disease  declines 
the  cough  gradually  disappears,  and  the  child  appears  to  be  suf- 
fering with  ordinary  bronchitis.  The  characteristic  whoop  may 
return  at  any  time  during  the  ensuing  six  months  or  year  if  the 
child  has  an  attack  of  bronchitis  and  is  inclined  to  cough. 

Complications  and  After-effects.  —  The  complications  and  after- 
effects of  whooping  cough  give  it  a  serious  character.  Hemor- 
rhage may  occur  from  the  nose.  According  to  Ruhrah :  "  Paralysis 
may  follow  from  meningeal  hemorrhage,  broncho-pneumonia, 
acute  empysema,  and  collapse  of  the  lung  may  occur.  Diarrhea, 
convulsions,  and  albuminuria  are  also  met  with.  Tuberculosis 
and  chronic  bronchitis  may  follow."  * 

Dietetic  Treatment.  —  The  diet  plays  an  important  part  in 
whooping  cough.     The  serious  complications  and  after-effects  of 

*  "Diseases  of  Infants  and  Children,"  p.  326,  by  Ruhrah. 


FEEDING  IN  INFECTIOUS  CONDITIONS        215 

this  disease  upon  children  necessitate  a  rigid  observance  of  dietary 
laws.  With  infants  it  is  always  best,  when  it  is  possible,  to  give 
breast  milk.  As  this  is  the  natural  food  it  requires  less  effort  on 
the  part  of  the  digestive  apparatus  to  become  available.  It  has 
been  proved  that  even  during  the  time  when  the  baby  is  nursing 
the  milk  is  projected  in  spurts  into  the  duodenum  without  waiting 
to  be  attacked  by  digestive  enzymes  in  the  stomach,  and  for  this 
reason  the  breast-fed  infant  is  more  apt  to  be  efficiently  nourished 
than  the  artificially  fed  baby,  who  loses  his  dinner  by  vomiting 
before  absorption  has  had  a  chance  to  occur. 

Diet  under  Ten  Years  of  Age.  —  For  children  under  ten  years, 
a  fluid  diet  is  necessary,  at  least  in  the  beginning  of  the  disease 
while  there  is  a  fever,  and  later,  if  the  vomiting  is  persistent.  Milk, 
buttermilk,  koumiss,  broths,  albumenized  beverages,  and  cereal 
gruels  such  as  barley  and  oatmeal  gruel  and  arrowroot  gruel  can 
be  given.  Later,  if  the  fluids  are  retained,  cream  of  wheat,  farina, 
junket,  soft  custards,  and  soft-cooked  eggs  may  be  added.  Care 
must  be  taken  in  giving  toast,  unless  it  is  softened  with  milk  or 
broth,  for  the  crumbs  may  bring  on  a  paroxysm  of  coughing  and 
vomiting.  The  best  results  in  feeding  with  whooping  cough  are 
obtained  by  giving  the  food  in  small  quantities  and  oftener.  A 
few  ounces  given  every  two  hours  are  less  apt  to  be  vomited  than 
a  larger  quantity.  It  is  also  easier  for  the  child  to  take  the  small 
amount  after  an  attack  of  coughing  and  vomiting  than  it  would 
be  for  him  to  attempt  a  larger  meal. 

Use  of  Stimulants.  —  In  many  cases  where  weakness  is  great, 
it  has  been  found  advisable  to  add  some  stimulant  to  the  diet. 
With  infants  this  is  best  given  in  albumen  water,  a  small  amount 
of  good  brandy  acting  better  than  other  stimulants.  With  young 
children  some  of  the  predigested  liquid  beef  preparations,  such  as 
liquid  peptonoids,  are  found  valuable.  These  foods  are  given 
alternately  with  the  other  fluid  foods. 

Hygiene  and  Sanitation.  —  Infants  and  children  suffering  with 
whooping  cough  require  plenty  of  fresh  air  and  sunshine.  They 
must  be  kept  out  of  doors  as  much  as  possible  and  sleep  in  well- 
ventilated  rooms  or  sleeping  porches.    They  must  be  protected 


216  DIETETICS  FOR  NURSES 

from  drafts  and  excitement,  and  never  allowed  to  become  over- 
tired. In  this  way  the  anemia  which  so  often  results  from  pro- 
longed attacks  of  whooping  cough  is  in  a  measure  held  in  check. 
At  times  it  is  found  necessary  to  give  some  kind  of  an  iron  tonic, 
but  this  comes  under  the  jurisdiction  of  the  physician  instead  of  the 
nurse.  When  bad  effects  do  occur  in  spite  of  all  the  care  exercised 
during  the  attack  of  whooping  cough,  they  must  be  accorded  the 
treatment  especially  devised  to  meet  the  situation. 

MEASLES 

This  is  an  acute,  infectious  disease  characterized  by  a  red  erup- 
tion which  appears  on  the  fourth  day.  Measles  is  one  of  the  most 
contagious  of  all  the  diseases  of  childhood.  It  may  be  acquired 
by  direct  contact  with  another  case  or  by  being  in  the  room  with 
a  case.  The  infection  may  also  be  carried  through  the  air  and 
occasionally  by  a  third  person.  Measles  is  more  prevalent  in  the 
winter  than  in  summer.  In  cities  it  often  occurs  in  epidemics. 
The  period  of  incubation  is  from  ten  days  to  three  weeks,  occur- 
ring generally  at  about  two  weeks  after  exposure. 

The  attack  may  begin  with  the  child  showing  a  languid  attitude, 
complaining  of  headache.  Then  a  cough  develops,  with  nausea 
and  fever  at  times.  The  fever  is  often  high,  reaching  104°  F.  on 
the  second  day.  As  a  rule  the  fever  gradually  falls  after  the  second 
day  and  becomes  normal  in  almost  a  week.  However,  the  tem- 
perature varies  in  different  cases. 

Complications.  —  Measles  is  not  considered  dangerous  in  itself, 
but  the  after-effects  sometimes  prove  fatal.  This  is  especially 
the  case  in  broncho-pneumonia,  which  frequently  develops  during 
or  after  the  attack. 

The  gastro-intestinal,  as  well  as  the  respiratory,  tract  is  attacked 
in  measles,  -diarrhea  being  especially  common.  Very  weak  chil- 
dren have  been  known  to  develop  gangrenous  stomatitis ;  paraly- 
sis and  tuberculosis  ^  likewise  develop  in  some  cases  as  the  direct 
result  of  measles. 

6  "A  Manual  of  Diseases  of  Children,"  p.  319,  by  Ruhrah. 


FEEDING  IN  INFECTIOUS  CONDITIONS        217 

Thus  it  is  demonstrated  that  measles  is  not  to  be  lightly 
treated.  Even  if  it  is  not  in  itself  fatal,  the  results  of  the  disease 
are  so  dangerous  that  the  care  of  the  nurse  is  especially  necessary. 
The  great  trouble  is  that  so  often  a  nurse  is  not  in  attendance  and 
the  child  suffers  through  ignorance  of  the  mother. 

Dietetic  Treatment.  —  The  dietetic  treatment  of  measles  is 
important.  For  infants  milk  is  the  exclusive  diet,  the  formula  for 
bottle-fed  babies  having  to  be  weakened  on  account  of  the  ca- 
tarrhal condition  of  the  gastro-intestinal  tract.  For  older  children 
it  is  necessary  to  confine  the  diet  to  fluids  as  long  as  the  fever  lasts, 
and  at  times  longer  if  the  stomach  gives  evidence  of  digestional 
disturbances.  Milk  is  the  chief  food,  with  milk  soups,  buttermilk, 
and  koumiss  used  to  vary  the  diet.  Orangeade  and  lemonade  may 
be  given  to  allay  thirst.  A  return  to  normal  diet  must  be  made 
gradually,  giving  cereal  gruels,  milk  toast,  and  broth  before  the 
more  solid  articles  of  diet  suitable  to  the  age  of  the  child.  When 
there  are  complications  they  must  be  treated,  as  in  whooping 
cough,  according  to  their  symptoms. 

SUMMARY 

Gastro-intestinal  Disturbances  are  responsible  for  much  of  the 
fever  manifested  during  infancy  and  childhood. 

Infectious  Diseases  are  all  more  or  less  accompanied  by  an 
elevation  of  temperature. 

Incipient  Diseases,  especially  tuberculosis  and  scurvy,  may 
likewise  cause  a  rise  of  temperature.  The  relief  of  either  disease 
or  the  fever  depends  largely  upon  how  quickly  the  conditions  are 
discovered  and  the  means  instituted  to  overcome  them. 

Metabolism  in  Febrile  Conditions  of  children,  as  well  as  of 
adults,  is  rapidly  increased,  hence  the  energy  output  is  greater, 
and  for  this  reason  the  fluid  intake  must  be  augmented  in  order 
to  eliminate  the  toxic  substances  produced  as  a  result  of  the 
rapid  breaking  down  of  the  body  tissues. 

The  Kidneys  are  more  or  less  strained  to  eliminate  the 
products  of  the  increased  metabolism  and  for  this  reason  it  is 
especially  necessary  to  adjust  the  diet  in  order  to  limit,  as  far  as 


218  DIETETICS  FOR  NURSES 

possible,  the  foods  which  add  to  the  burden  already  imposed  upon 
the  organs  of  excretion. 

The  Skin  is  an  organ  of  excretion  which,  under  normal  con- 
ditions, shares  the  work  of  the  kidneys.  In  infectious  condi- 
tions, accompanied  by  eruptions  which  more  or  less  cover  the 
entire  surface  of  the  body,  this  organ  is  temporarily  out  of  com- 
mission, hence  its  work,  as  well  as  their  own,  must  be  accomplished 
by  the  kidneys. 

Dietetic  Treatment  in  the  majority  of  infectious  diseases 
may  be  divided  into  three  periods :  Starvation,  Fluid  Diet,  and 
Convalescent  Diet. 

Starvation,  during  which  time  no  food  is  given  for  twenty-four 
hours  or  longer,  in  order  to  allow  the  digestional  apparatus  to  rest 
and  to  give  time  for  any  substance  which  may  be  causing  the  ele- 
vation of  the  temperature  to  pass  from  the  body.  This  treatment 
is  also  wise  because  it  furnishes  an  opportunity  for  the  symptoms 
of  the  disease  to  manifest  themselves;  Fluid  Diet,  given  when 
acute  symptoms  subside,  and  Convalescent  Diet  when  danger 
from  relapse  is  over. 

Scarlet  Fever  is  treated  with  two  main  ideas  in  view  —  pre- 
venting the  development  of  nephritis  and  relieving  the  condition 
should  it  develop. 

Diet  Treatment  is  logically  the  only  means  of  treating  or 
relieving  nephritis.  For  the  first  three  weeks,  during  which 
time  this  complication  is  apt  to  develop,  a  milk  diet  is  necessary. 
This  may  be  in  the  form  of  whole  milk,  milk  soups,  malted  milk, 
etc.  At  the  end  of  this  time,  if  there  are  still  no  symptoms  of  ne- 
phritis, a  convalescent  diet,  beginning  with  cereals  and  soft  toast 
and  progressing  through  the  simple  digestible  foods  such  as  rice, 
baked  potatoes,  soft  eggs,  etc.,  may  be  given.  This  is  continued 
until  the  patient  is  well  on  the  road  to  recovery.  Meat  should 
not  be  added  until  practically  all  danger  of  nephritis  is  passed. 

Nephritis.  —  If,  during  the  course  of  the  disease  this  compli- 
cation should  develop,  the  treatment  described  for  acute  ne- 
phritis on  page  307  should  be  immediately  instituted. 

Diphtheria.  —  Dangerous  complications  at   times   develop   as 


FEEDING  IN  INFECTIOUS  CONDITIONS        219 

a  result  of  diphtheria,  making  the  treatment  of  this  disease  of 
the  utmost  importance.  Heart  symptoms,  pneumonia,  albumi- 
nuria, and  anemia  are  among  the  complications  to  be  dreaded  and 
combated. 

Dietetic  Treatment  in  diphtheria  is  most  important.  It  con- 
sists of  a  fluid  diet  made  up  of  milk,  malted  milk,  or  buttermilk. 
At  times  the  condition  of  the  throat  makes  a  slightly  thickened 
mixture  more  easily  swallowed  than  one  which  is  distinctly  fluid 
in  character,  and  for  this  purpose  farina,  arrowroot,  or  barley  flour 
may  be  used. 

Increasing  the  Diet.  —  As  convalescence  advances  the  semi- 
solids, soft  toast,  soft  custards,  gelatine,  and  cereals  may  be  given. 
Should  the  heart  show  symptoms  of  being  affected,  the  intake  of 
fluid  must  be  restricted. 

Gavage  and  Rectal  Feeding  are  at  times  necessary.  In- 
fants may  be  successfully  fed  by  passing  a  small  rubber  tube 
through  the  nose  into  the  stomach  and  administering  the  milk 
formula  to  which  they  are  accustomed.  Rectal  feeding  is  likewise 
valuable  in  cases  of  extreme  anemia  accompanying  diphtheria. 

Care  must  be  observed  by  the  nurse  in  giving  gavage  to  babies, 
since  any  struggling  on  the  part  of  the  child  may  result  in  death 
from  heart  disease. 

Whooping  Cough.  —  On  account  of  the  character  of  the  disease 
and  the  proneness  of  the  stomach  to  eject  the  food  during  par- 
oxysms of  coughing,  dietary  measures  are  more  or  less  necessary 
in  order  to  enable  the  child  to  receive  sufficient  food  to  cover  his 
daily  needs. 

Complications.  —  Hemorrhage,  pneumonia,  albuminuria,  diar- 
rhea, and  convulsions  during  the  course  of  the  disease,  while  tuber- 
culosis and  chronic  bronchitis  may  follow  as  after-effects. 

Dietetic  Treatment.  —  Breast  milk  is  by  far  the  best  food  for 
the  baby,  in  this  as  in  all  conditions.  In  whooping  cough  the  fact 
that  this  fluid  leaves  the  stomach  almost  as  soon  as  it  enters 
lessens  the  chances  of  the  baby  losing  its  meal  by  vomiting  it. 

Older  Children  do  well  with  frequent  small  meals,  since 
they  are  not  so  apt  to  give  rise  to  pressure  which  brings  on  the 


220  DIETETICS  FOR  NURSES 

paroxysms  of  coughing  and  vomiting.  When  the  meal  is  vomited, 
a  second  should  be  given  in  order  to  keep  the  child  from  suffering 
from  malnutrition. 

Stimulation  is  found  to  be  necessary  in  certain  cases.  Al- 
bumen water  containing  a  spoonful  of  brandy  or  some  of  the  pre- 
pared beef  preparations,  such  as  liquid  peptonoids,  may  prove 
valuable  under  the  circumstances. 

Measles.  —  Complications  and  after-effects  developing  as  a 
result  of  measles  make  the  dietetic  treatment  of  this  disease  im- 
portant. Gastro-intestinal  disturbances,  especially  diarrhea,  are 
apt  to  occur,  and  tuberculosis  has  been  known  to  develop  as  a 
result  of  measles. 

Dietetic  Treatment.  —  The  fluid  diet  as  used  in  any  acute  febrile 
condition  is  used  as  long  as  the  temperature  is  elevated.  Milk, 
buttermilk,  malted  milk,  and  milk  soups  constitute  the  chief  items 
in  the  diet.  Orangeade  and  lemonade  are  found  valuable  in  reliev- 
ing the  thirst. 

formulas  used  in  feeding  infants 

Whey 

Put  one  pint  of  skimmed  milk  into  a  clean  saucepan  and  heat 
to  a  temperature  of  100°  F.  (lukewarm).  To  this  milk  add  2  tea- 
spoonfuls  of  liquid  rennet,  essence  of  pepsin,  or  2  junket  tablets, 
stir  until  well  mixed,  and  allow  to  stand  at  room  temperature 
(70°  F.)  until  firmly  jellied.  Break  up  with  a  fork  until  it  is  finely 
divided,  strain  through  thicknesses  of  cheesecloth;  return  the 
fluid  part  to  the  stove  and  raise  to  a  temperature  of  150°  F.  to 
destroy  the  rennet  left  in  the  whey.  The  whey  is  then  cooled  be- 
fore it  is  added  to  the  milk  or  cream. 

Barley  Water 

3%  decoction  starch^ 

4  rounded  tsp.  barley  flour 

1  pt.  water 

« When  a  1.50%  decoction  is  desired,  use  2  rounded  teaspoonfuls  to  the  pint  of 
water.     "Diseases  of  Nutrition  and  Infant  Feeding,"  p.  222,  by  Morse  and  Talbot. 


FORMULAS  USED  IN  FEEDING  OF  INFANTS    221 

Mix  a  small  amount  of  the  water  with  the  barley  flour  and  put 
the  rest  of  the  water  into  a  clean  saucepan  and  allow  to  heat ;  when 
boiling  add  thin  barley  mixture,  stir  thoroughly,  and  allow  to  boil 
20  minutes ;  remove  from  stove,  measure,  and  replace  with  hot 
water  that  which  was  lost  through  evaporation  to  make  up  the 
original  pint ;  strain  through  two  thicknesses  of  cheesecloth. 

Oat  Water 

4  rounded  tsp.  oat  flour 

1  pt.  water 

Mix  and  proceed  as  in  making  barley  water 

Albumen  Water  with  Brandy 

8  oz.  water  (cold) 
1  egg  white 
1  tsp.  brandy 
Mix  egg  and  water  and  add  brandy  slowly  to  prevent  coagulat- 
ing egg  white. 

Buttermilk  Mixture  for  Infants 
644'^  calories 

1  tbs.  wheat  flour,  4  tbs.  dextri-maltose,  8  oz.  hot  water  plus 
enough  hot  water  to  replace  that  which  is  lost  through  evaporation 
(about  6  oz.).  Buttermilk,  sufficient  quantity  to  make  1  quart  of 
mixture.  Mix  flour  with  a  little  cold  buttermilk.  Dissolve  sugar 
(dextri-maltose)  in  the  hot  water. 

Stir  two  mixtures  together  and  add  enough  buttermilk  to  make 
1  quart.  Place  on  stove  and  bring  mixture  quickly  to  a  boil. 
Boil  for  20  minutes,  stirring  constantly,  strain,  measure,  and  add 
enough  boiling  water  to  replace  that  which  is  lost  in  cooking. 
Place  on  ice  and  use  as  directed. 

The  nurse  will  soon  be  able  to  tell  how  much  water  is  lost  in 
evaporation  and  add  the  additional  amount  to  the  mixture  before 
beginning  the  boiling. 


222      .  DIETETICS  FOR  NURSES 

Malt  Soup 

SJ^7  calories 

1^-2  tbs.  malt  soup  extract  (reduce  if  necessary) 

1  level  tbs.  sifted  flour 

1  pt.  milk 

18  oz.  water  (hot  and  cold) 

Dissolve  malt  soup  extract  in  |  cup  of  hot  water  and  measure 
in  enough  cold  water  to  cool  the  mixture.  With  the  remaining 
cold  water  mix  the  flour  until  it  is  free  from  lumps ;  add  to  the 
malt  soup  mixture,  add  milk.  Pour  all  into  a  clean  saucepan  and 
bring  slowly  to  the  boiling  point ;  simmer  (not  boil)  for  20  min- 
utes. Now  increase  the  heat  and  allow  the  mixture  to  boil  5 
minutes;  strain  and  use  as  directed. 

This  is  a  fattening  mixture  and  the  amount  of  malt  soup  and 
whole  milk  may  be  increased  as  the  child  is  able  to  handle  it,  taking 
care,  however,  not  to  increase  the  strength  of  the  mixture  too 
rapidly  or  too  much,  or  digestional  disturbances  will  result. 

The  following  milk  formulas  are  used  in  the  Nathan  Straus  Pas- 
teurized Milk  Laboratories  of  New  York : 

Formula  No.  1.     Infants  from  1st  to  4th  week,  by  A.  R.  Green. 
24  ounces  of  mixture  divided  into  8  feedings  of  three  ounces 
each,  fed  at  intervals  of  2f  hours : 

J  oz.  16%  cream 
3  oz.  full  milk 
19  oz.  water 
Ij  oz.  limewater 
1|  oz.  milk  sugar 

Formula  No.  2.     Infants  1st  to  3d  month,  by  Dr.  R.  G.  Freeman. 

1^  oz.  16%  cream 

3  oz.  full  milk 

13  oz.  water 

J  oz.  limewater         , 

1  oz.  milk  sugar 
Divided  into  6  feedings  of  3  oz.  each,  fed  3  hours  apart. 


FORMULAS  USED  IN  FEEDING  OF  INFANTS     223 

Formula  No.  3.     Infants  2d  to  6th  month,  by  Dr.  R.  G.  Free- 
man. 

18  oz.  full  milk 
16|  oz.  water 
1|  oz.  limewater 
1|  oz.  milk  sugar 
Divided  into  6  feedings  of  6  ounces  each,  fed  at  intervals  of  3 
hours. 

Formula  No.  4.     Infants  3d  to  7th  month,  by  Dr.  A.  Jacobi. 
18  oz.  full  milk 
18  oz.  barley  water 
1  oz.  cane  sugar 
20  grains  salt  (less  than  J  tsp.) 
Divided  into  6  feedings  of  6  ounces  each,  fed  at  intervals  of 
3  hours. 

Formula  No.  5.     Infants  7th  to  9th  month,  by  Dr.  A.  Jacobi. 

2|  oz.  full  milk 

7|  oz.  oat  or  barley  water 

Ij  oz.  cane  sugar 

30  grains  (about  |  tsp.)  table  salt 
Divided  into  5  feedings  of  6  ounces  each,   fed  at  intervals  of 
3 J  hours. 

Beef,  Mutton,  or  Chicken  Broth 

1  lb.  lean  meat 

1  lb.  bones 
or 

2-lb.  hen 

1  qt.  cold  water 

J  tsp.  salt 
Cut  meat  in  small  pieces,  crack  bones,  or  cut  chicken  as  for  fry- 
ing. Place  in  a  clean  saucepan  and  cover  with  cold  water ;  cover 
and  simmer  gently  from  two  to  three  hours ;  strain  and  measure ; 
add  enough  hot  water  to  replace  that  which  was  lost  through 
evaporation.  Allow  broth  to  become  thoroughly  cold  and  skim 
carefully  to  remove  fat.     Pass  a  piece  of  tissue  paper  or  absorbent 


224  DIETETICS  FOR  NURSES 

cotton  or  blotting  paper  across  the  top  to  remove  the  last  particles 
of  grease  that  may  have  escaped.  Place  on  ice.  The  broth  should 
jelly.  Two  ounces  should  be  given  at  noon.  This  amount  may 
be  increased  to  4  ounces.  Bread  crumbs  or  zwieback  may  be  added 
to  the  broth  after  a  few  weeks. 

Junket 

Part  of  the  milk  given  the  baby  may  be  made  into  junket  after 
the  baby  is  a  year  old. 

I  pt.  (1  cupful)  milk 

J  junket  tablet  or  1  tsp.  essence  of  pepsin 
1-2  tsp.  sugar 

Flavor  with  a  few  drops  of  vanilla,  if  desired 
Heat  the  milk  to  lukewarm  (not  over  100°  F.  or  the  rennet  will 
be  destroyed). 

Add  sugar  and  flavoring ;  dissolve  junket  in  a  teaspoonful  of 
cold  water,  stir  into  the  milk ;  allow  to  stand  at  room  tempera- 
ture (from  70°-75°  F.)  until  firmly  jellied ;   then  place  on  ice. 

Prunes 

Prunes  should  be  carefully  selected.  As  a  rule  the  cheap  varie- 
ties are  little  else  than  skin  and  stone. 

Place  1  pound  of  prunes  in  a  saucepan  and  cover  well  with  water. 
Simmer  gently  from  2  to  3  hours,  then  sweeten  moderately ;  a 
quarter  of  a  cup  of  sugar  should  be  ample  to  swerten  1  pound  of 
prunes  after  they  have  been  cooked. 

Stir  the  sugar  into  the  hot  juice,  allow  to  cook  10  minutes.  Re- 
move from  saucepan ;  place  in  glass  jar  and  use  as  needed. 

Prune  pulp  may  be  made  by  pressing  the  prunes  cooked  as 
directed  through  a  fine  strainer. 

When  prunes  are  to  be  used  primarily  for  their  laxative  effect, 
1  tablespoonful  of  senna  leaves  may  be  added  during  the  last 
hour  of  cooking  and  carefully  strained  out  before  placing  the 
prunes  in  the  glass  jar. 

One-half  pound  each  of  prunes  and  figs  may  be  cooked  together 


FORMULAS  USED   IN  FEEDING   OF  INFANTS    225 

in  a  like  manner  and  may  be  used  instead  of  prunes  alone  for  older 
children  who  suffer  from  constipation. 

Bran  biscuits,  muffins,  cookies,  etc.,  may  be  given  to  children 
suffering  from  constipation. 

Beef  Juice 

Composition :  0.60%  fat,  2.90%  protein,  and  considerable  ex- 
tractive matter."^ 

Place  a  piece  of  round  steak  upon  a  hot  griddle  and  turn  once 
or  twice  until  the  outside  is  seared  and  the  meat  is  hot  throughout. 
Remove  from  griddle  and  cut  into  small  pieces  and  place  in  a  small 
meat  press  made  for  the  purpose.  A  lemon  squeezer  may  be  used 
when  the  press  is  not  available.  Salt  lightly.  Begin  by  giving 
one  teaspoonful  and  increase  the  amount  gradually  to  1  ounce  (6 
teaspoonfuls).  According  to  Morse  and  Talbot,  it  is  never  wise 
to  give  babies  more  than  2  ounces  of  beef  juice  even  in  their 
second  year,  as  it  is  apt  to  disturb  digestion.  Also  babies  are  often 
made  restless  or  sleepless  by  taking  beef  juice.* 

'  "Beef  juice  is  not  the  same  as  'dish  gravy,'  since  the  latter  contains  a  large 
amount  of  cooked  fat  and  is  often  highly  indigestible."  Morse  and  Talbot's 
"Diseases  of  Nutrition  and  Infant  Feeding.". 


CHAPTER    XIII 

THE    FEEDING   OF   ADULTS    IN    DISEASES   OF   THE 
GASTRO-INTESTINAL  TRACT 

ACUTE   AND    CHRONIC   GASTRITIS 

Predisposing  Factors.  —  The  majority  of  diseases  affecting  the 
stomach  have  as  their  predisposing  factors,  and  owe  their  develop- 
ment to,  one  or  all  of  the  following  conditions  :  (1)  errors  in  diet ; 
(2)  disturbed  secretory  processes;  (3)  disturbed  motility  and 
tone. 

It  is  probable  that  in  the  beginning  the  first  factor  was  the  chief 
offender  in  the  case,  bringing  about  the  development  of  one  or  both 
of  the  other  conditions.  The  other  factors  to  be  considered  in 
this  respect  are  heredity,  occupation,  poverty,  and  diseases  which 
involve  to  a  greater  or  lesser  degree  the  digestion  of  the  stomach 
and  intestines.  A  child  may  inherit  a  weakened  organism  through 
excesses  or  disease  on  the  part  of  the  parent.  If  this  weakness 
is  not  overcome  while  the  child  is  growing,  the  probabilities  are 
that  the  digestion  steadily  declines  until  in  adult  life  it  becomes  a 
pathological  condition.  Lack  of  fresh  air,  poor  and  dirty  food, 
unwholesome  surroundings,  crowded  and  badly  ventilated  sleep- 
ing rooms,  insufficient  water,  and  overwork,  all  act  in  making  the 
digestion  bad.  These  must  be  overcome  if  permanent  good  is  to 
result. 

Errors  in  Diet.  —  Errors  in  diet  arise  more  often  through 
ignorance  than  from  any  other  cause.  A  child  may  be  allowed  to 
eat  any  and  all  kinds  of  unwholesome  and  unsuitable  food.  When 
the  stomach  rebels,  showing  the  serious  danger  signals  of  nature, 
medicines  are  given  but  the  diet  is  unheeded,  until  the  time  comes 
when  even  the  medicines  fail  to  give  temporary  relief,  and  the 
organs  of  digestion  are  in  some  instances  permanently  impaired. 

226 


THE  FEEDING  OF  ADULTS  227 

Disturbed  Secretory  Processes.  —  Consensus  of  opinion  goes 
to  show  that  the  majority  of  cases  of  acute  and  chronic  gastritis 
(catarrhal)  and  gastric  ulceration  are  due  primarily  to  a  dis- 
turbance of  the  secretory  processes,  while  the  impaired  motility 
and  lack  of  tone  in  the  stomach  probably  influence  their  develop- 
ment and  aggravate  the  disease  already  present. 

Composition  of  Gastric  Juice.  —  In  a  former  chapter  the 
processes  of  gastric  digestion  were  explained.  The  gastric  juice, 
composed  of  from  0.2  to  0.3%  free  hydrochloric  acid  and  several 
important  enzymes  and  lipases,  which  act  upon  the  proteins  and 
emulsified  fats,  must  be  sufficient  in  quantity  to  assure  good  di- 
gestion, and  when  anything  arises  to  interfere  with  the  secretion 
of  this  fluid  a  deviation  from  the  normal  is  bound  to  occur. 

Disturbed  Motility  and  Tone.  —  Again,  it  has  been  proved  that 
good  gastric  digestion,  like  good  intestinal  digestion,  depends  more 
or  less  upon  the  way  in  which  the  food  mass  is  mixed  with  the 
digestive  juices  and  moved  along  the  alimentary  canal.  Any- 
thing which  interferes  with  the  secretion  of  the  juices  or  delays 
the  food  over  its  normal  length  of  time  in  the  stomach  surely 
exerts  unfavorable  influences  on  the  general  metabolism  of  the 
food,  for  while,  as  we  have  already  found,  gastric  digestion  is  not 
essential  to  the  final  utilization  of  the  food  in  health,  in  disease 
it  undoubtedly  exerts  a  marked  influence  upon  the  general  nutrition 
of  the  individual. 

HYPOCHLORHYDRIA 

The  lack  of  hydrochloric  acid  in  the  gastric  juice  lowers  the  re- 
sistance to  bacterial  action,  for  this  constituent  exerts  a  decided 
germicidal  influence  in  gastric  digestion,  preventing  fermentation 
with  the  production  of  organic  acids  and  probably  alcohol.  In 
conditions  due  to  hypochlorhydria  (lack  of  hydrochloric  acid) 
foods  which  leave  the  stomach  quickly  must  be  given  with  enough 
of  the  other  necessary  constituents  in  their  simplest  and  most 
easily  digested  form  to  balance  the  diet  and  prevent  the  occur- 
rence of  the  other  disorders  as  troublesome  as  the  original  dis- 
order. 


228  •    DIETETICS  FOR  NURSES 

Dietetic  Treatment.  —  The  following  points  must  be  kept  in 
mind  in  formulating  a  dietary  for  patients  suffering  from  a  defi- 
ciency of  hydrochloric  acid  :  (1)  boil  the  drinking  water  to  destroy 
any  bacteria  which  may  be  present ;  (2)  use  carbohydrates  in  the 
form  of  starch  rather  than  sugar,  since  starch  is  less  liable  to 
fermentation  from  bacteria  than  sugar ;  (3)  limit  the  foods  which 
delay  the  passage  of  the  food  mass  from  the  stomach ;  fats  pass 
into  the  duodenum  more  slowly  than  other  foods  and  when  fed  with 
other  foods  delay  their  passage  materially;  (4)  avoid  the  use 
of  soda  bicarbonate,  as  it  tends  to  reduce  the  normal  acid  content 
of  the  stomach,  thus  preventing  its  germicidal  action  upon  the 
fermentative  bacilli ;  alkaline  carbonates  likewise  inhibit  the  flow 
of  gastric  juices ;  (5)  give  especial  attention  to  the  attractiveness 
of  the  food  served;  let  it  be  appetizing  and  savory,  for  by  such 
means  is  the  appetite  juice  and  incidentally  an  increased  flow  of 
the  gastric  juices  stimulated ;  (6)  condiments  and  spices,  meat 
broths  high  in  extractives,  and  salt  foods  such  as  caviar  and 
endives  may  be  given  at  the  discretion  of  the  physician  ;  it  is  seldom 
advisable  to  give  the  foods  which  are  indigestible,  even  when  they 
act  as  stimulants  to  the  secretory  cells  of  the  stomach. 

HYPERCHLORHYDRIA 

(Excess  secretion  of  acid  in  the  stomach) 

The  Effect  of  Excess  Acid.  —  An  excessive  flow  of  hydrochloric 
acid  has  been  found  to  be  the  cause  of  much  of  the  acute  and  chronic 
gastritis,  in  fact  more  of  the  cases  are  traceable  to  an  excess  than 
to  a  lack  of  hydrochloric  acid.  This  acid  is  more  or  less  irritating 
in  character,  and  the  tender  mucous  membranes  lining  the  gastric 
organ  being  constantly  bathed  in  a  secretion  composed  chiefly 
of  acid  must  necessarily  in  time  suffer  a  certain  amount  of 
irritation  and  inflammation,  causing  the  development  of  a  patho- 
logical condition  which  may  be  temporary  or  permanent,  that  is,  it 
may  result  in  acute  or  chronic  gastritis,  according  to  the  amount  of 
acid  secreted  and  the  length  of  time  the  hypersecretion  is  allowed 
to  continue. 


THE  FEEDING  OF  ADULTS  229 

Determining  the  Acid  Content  of  Stomach.  —  The  difference 
between  the  cases  brought  about  by  an  excess  flow  of  hydrochloric 
acid  are  more  or  less  difficult  to  distinguish  from  those  caused 
by  a  lack  of  this  constituent  in  the  gastric  juice,  chiefly  because  in 
the  latter  case  the  organic  acids  formed  as  the  result  of  bacterial 
action  upon  the  food  exert  an  equally  irritating  effe;ct  upon  the 
membranes  of  the  stomach,  and  the  only  sure  method  of  determin- 
ing the  cause  of  the  disturbance  is  by  an  analysis  of  the  stomach 
contents,  by  which  means  the  percentage  of  hydrochloric  acid  is 
determined. 

Lavage.  —  It  has  been  found  advisable,  in  some  cases  of  acute 
gastritis  which  do  not  yield  readily  to  rest  and  liquid  diet,  to  wash 
the  stomach  and  allow  a  certain  period  of  rest  before  giving  any 
food ;  in  this  way  the  organ  is  rid  of  all  of  the  offending  material 
and  thus  has  a  better  chance  of  a  quick  recovery. 

ACUTE   GASTRITIS 

Dietetic  Treatment.  —  The  following  dietetic  treatment  for 
acute  gastritis  is  advised :  As  the  stomach  is  the  chief  seat  of 
disturbance,  all  unnecessary  work  must  be  taken  from  this  region 
for  a  certain  period  : 

(1)  That  any  obscure  cause  may  manifest  itself  and  the  diagnosis 
may  be  rendered  more  accurately  and  more  quickly. 

(2)  That  by  resting  the  organ  the  offending  materials  may  pass 
out  of  the  body  and  thus  prevent  further  trouble. 

Starvation  Period.  —  Twenty-four  hours  of  total  abstinence 
from  food  may  seem  extreme,  but  as  a  rule  in  acute  cases  of  gastritis 
it  is  the  only  sane  and  safe  method  of  instituting  a  diet  and  thus 
beginning  to  overcome  the  cause  of  the  disturbance.  After  the 
period  of  starvation  the  diet  is  begun  with  caution. 

Fluid  Diet.  —  Fluids  should  be  given  first  in  the  form  of  well- 
skimmed  broths,  which  may  be  reenforced  with  egg  or  cereal 
flours  when  the  patient  is  very  thin  or  anemic.  Buttermilk,  made 
with  the  Bulgarian  cultures,  koumiss  and  other  fermented  milk 
foods,  liquid  beef  preparations  such  as  peptonoids  or  panopepton, 
albumenized  orange  juice,  cereal  gruels  treated  with  Taka  diastase 


230  DIETETICS  FOR  NURSES 

when  it  is  found  necessary,  and  peptonized  milk.  These  may  be 
given  in  from  four  to  six  ounces  at  a  time,  every  two  hours  on  the 
second  day. 

Increasing  the  Diet.  —  On  the  third  day  if  the  attack  is  slight 
the  diet  may  be  increased  by  adding  toast,  softened  with  pep- 
tonized milk,  an  ordinary  serving  (3  ounces)  of  farina,  cream  of 
wheat  or  rice,  reenforced  meat  broth  with  two  crackers,  a  cup 
of  tea  and  a  slice  of  toast,  and  one  or  two  soft-cooked  eggs.  If  the 
acute  symptoms  are  still  present  on  the  third  day,  the  diet  advised 
for  the  second  day  must  be  continued  until  they  disappear. 

Convalescent  Diet.  —  On  the  fifth  day,  if  progress  is  satisfactory, 
lightly  broiled  chicken  or  a  small  piece  of  rare  broiled  beefsteak 
may  be  added  to  the  diet  and  the  meals  reduced  in  number  from 
six  to  four. 

Relapse.  —  The  patient  must  be  warned  against  over-eating  or 
eating  any  of  the  articles  which  are  known  to  cause  an  acute  attack 
in  his  individual  case,  since  one  attack  predisposes  to  another,  and 
chronic  gastritis  may  develop  as  the  result  of  the  continual  gastric 
disturbance. 

CHRONIC    GASTRITIS 

The  treatment  in  chronic  gastritis  is  very  like  that  in  the  more 
acute  form ;  that  is,  it  must  be  combated  by  removing  the  cause. 
Lack  of  fresh  air  and  exercise  have  much  to  do  with  the  develop- 
ment of  chronic  gastritis,  but  even  they  combined  with  a  judicious 
amount  of  rest  would  be  wasted  without  a  proper  adjustment  of  the 
diet  to  cover  the  main  points  of  the  disturbance.  As  has  already 
been  mentioned,  the  cause  may  be  a  lack  of  gastric  juice  or  it 
may  be  an  excess  of  it ;  it  may  be  intensified  by  an  atonic  con- 
dition of  the  organ  or  from  the  food  passing  too  quickly  into  the 
duodenum. 

Test  Meals.  —  As  a  rule  it  is  not  safe  to  make  a  snap  diagnosis 
as  to  the  cause  of  this  disorder.  Since  in  many  instances  the  more 
serious  disorders  may  be  traced  to  a  disregard  for  nature's  danger 
signals,  the  physician  as  a  rule  advises  a  test  meal,  this  meal 
consisting  of  a  glass  and  a  half  of  water  or  a  cup  or  two  of  tea  with- 


THE  FEEDING  OF  ADULTS  231 

out  cream  or  sugar  and  from  one  to  two  slices  of  toast  or  water 
rolls.  In  from  three-fourths  to  one  hour  or  longer  this  is  removed 
from  the  stomach  by  means  of  a  stomach  pump  and  analyzed, 
the  result  of  the  chemical  and  bacterial  analyses  forming  the  bases 
for  diagnosis.  This  meal  is  generally  given  in  the  morning  before 
any  other  food  has  been  eaten. 

Dietetic  Treatment.  —  The  foods  constituting  the  diet  in  chronic 
gastritis  must  be  of  the  simplest  character  and  prepared  in  the 
simplest  manner.  No  fried  foods  are  permissible.  Pastries, 
griddle  cakes,  rich  puddings  and  sauces,  candies,  and  alcoholic 
beverages  must  be  omitted  from  the  diet  as  well  as  the  following 
articles  of  food :  pork,  veal,  shellfish  except  oysters,  sardines, 
canned  meats  and  canned  fish,  highly  seasoned  and  spiced  dishes, 
twice-cooked  meats,  vinegar,  pickles,  olives,  cold  slaw,  pickled 
beets,  catsup,  mustard,  coarse  fibered  vegetables  such  as  cabbage, 
old  onions,  old  turnips,  and  cucumbers,  strong  tea,  coffee,  or 
chocolate,  rich  cream  or  dishes  made  entirely  of  cream.  In  cases 
of  excessive  acidity  due  to  a  hypersecretion  of  HCl  the  extractives 
of  meat  are  contraindicated,  hence  all  gravies  and  outside  parts 
of  roasted  meat  must  be  omitted  or  limited  in  the  diet. 

GASTRIC   ULCERATION 

Gastric  ulcer  may  develop  without  an  apparent  cause.  As  a 
rule,  however,  it  manifests  itself  in  individuals  between  fifteen 
and  forty,  particularly  after  prolonged  digestional  disturbances, 
especially  those  accompanied  by  a  hypersecretion  of  acid.  As  the 
disease  progresses,  anemia  is  more  or  less  severe,  adding  difiiculty 
to  the  feeding  problem.  Many  of  the  symptoms  are  like  those  of 
chronic  gastritis,  such  as  pain.  However,  the  character  of  this 
pain  may  be  different,  beginning  soon  after  eating  and  radiating 
toward  the  back.  This  point  may  be  affected  by  position.  As  a 
rule  there  is  a  tenderness  over  the  seat  of  the  ulcer.  This  is 
detected  by  palpation.  Vomiting  is  one  of  the  most  general  symp- 
toms in  gastric  ulceration.  This  may  begin  from  one  to  two  hours 
after  eating  when  the  pain  is  at  its  height,  or  it  may  start  as  soon 
as  food  enters  the  stomach.    As  a  rule  the  latter  condition  is  found 


232  DIETETICS  FOR  NURSES 

more  often  in  very  nervous  women  whose  mental  attitude  affects 
the  stomach  to  such  an  extent  as  to  make  it  difficult  to  give  them 
sufficient  food  to  nourish  them. 

Hemorrhage.  —  Hemorrhage  occurs  in  about  half  of  the  cases. 
The  bleeding  may  be  profuse  and  the  blood  bright  red,  or  it  may  be 
less  severe  and  the  color  of  the  blood  changed  by  contact  with  the 
gastric  juices  to  a  dark  brown  like  coffee  grounds. 

Excess  Acid.  —  Hyperacidity  is  present  in  the  majority  of  the 
cases,  the  percentage  of  HCl  rising  at  times  fifty  per  cent  or  more. 
Other  cases  occur  in  which  all  of  the  just  mentioned  symptoms 
except  dyspepsia  are  missing,  the  first  intimation  of  the  ulcer 
being  hemorrhage  or  perforation. 

The  patient  with  gastric  ulcer  may  recover  entirely  and  never 
have  a  return  of  the  trouble,  but  care  and  close  attention  are 
necessary,  since  the  ulcers  are  apt  to  recur,  at  times  a  series  of 
ulcers  developing  one  after  another.  Death  may  occur  from 
exhaustion  or  from  perforation  and  peritonitis.  Surgical  inter- 
vention is  as  a  rule  necessary  when  the  ulcers  persist,  as  they 
generally  develop  at  or  near  the  pyloric  opening ;  and  the  constant 
development  of  cicatricial  tissue  brings  about  an  obstruction  of  the 
pylorus,  which  if  not  relieved  would  allow  the  patient  to  starve. 

Diet  Treatments.  —  There  are  a  number  of  treatments  used 
in  overcoming  this  condition.  After  the  test  meal  and  the  diagno- 
sis, the  patient  is  placed  upon  a  diet  directed  to  overcome  the 
chief  symptom ;  for  example,  if  the  ulcer  developed  as  a  result  of 
hyperacidity,  the  diet  would  be  directed  toward  the  relieving  of 
that  symptom.  Boas  ^  divides  the  treatment  into  three  stages : 
(1)  hemorrhage;  (2)  the  intermediate  stage;  (3)  the  convalescent 
stage. 

Starvation  Treatment.  —  The  majority  of  physicians  institute 
a  total  abstinence  period  for  the  first  stage,  allowing  no  food  or 
water  to  be  taken  by  mouth.  If  the  patient  is  very  weak  and 
anemic  from  the  extended  course  of  the  disease,  nutrient  enemas 
are  given  from  four  to  six  times  a  day,  alternating  with  saline 
enemas.    This  total  abstinence  continues  from  three  to  six  days. 

*  "Diseases  of  the  Stomach,"  by  Boas. 


THE  FEEDING  OF  ADULTS  233, 

Some  cases  have  been  know  to  be  fed  in  this  way  for  a  month  or 
six  weeks  with  obvious  success.  However,  this  is  not  the  rule 
but  the  exception.  The  diet  must  be  adjusted  to  the  needs  of 
each  individual,  but  a  few  general  rules  may  be  found  helpful. 

Dietetic  Treatment.  —  Milk  is  the  food  generally  utilized  in 
the  beginning.  This  may  require  peptonizing  to  be  digested, 
or  it  may  have  to  be  modified  with  limewater.  Protein  foods 
require  HCl  for  their  digestion.  If  these  foods  are  fed  they  will 
absorb  some  of  the  excess  acid,  and  in  this  way  save  the  already 
irritated  wall  of  the  organ  from  additional  ifritation.  When 
protein  foods  are  given  they  must  be  in  the  form  of  soft-cooked 
eggs,  scraped  raw  beef  or  beef  juice,  milk  soups,  and  like  protein 
foods. 

When  there  is  a  dilatation  of  the  organ  there  is  more  or  less 
danger  of  fermentation  taking  place,  with  the  formation  of  organic 
acids.  These  acids  are  exceedingly  irritating,  and  every  care 
must  be  observed  to  prevent  their  production.  The  following 
dietetic  regime  may  be  used  as  a  guide  in  many  cases  of  gastric 
ulceration : 

Milk  Diet.  — i  glass  (4  ounces)  of  milk  peptonized  at  115°  F. 
for  20  minutes,  every  hour  for  three  or  four  days.  After  this  the 
interval  between  feedings  is  lengthened  to  two  hours  and  the 
amount  of  milk  increased  to  f  of  a  glass  (6  ounces).  This  is  con- 
tinued from  a  week  to  ten  days.  The  patient  may  be  given  a 
cup  of  well-strained  meat  broth,  reenforced  with  an  egg,  once  or 
twice  a  day,  to  vary  the  monotony  of  the  diet.  During  the 
third  week  the  milk  may  be  given  in  the  form  of  milk  soups.  These 
may  be  slightly  thickened  with  barley,  rice,  or  farina  flour.  The 
soups  may  be  flavored  with  beef  extract,  but  only  a  small  quantity 
must  be  used,  owing  to  the  stimulating  properties  of  these  sub- 
stances. 

Water  as  a  Stimulus  to  Gastric  Secretion. — Water  is  exceedingly 
stimulating  to  the  acid  secreting  cells  of  the  stomach,  hence  it  is 
advisable  to  limit  the  amount  of  water  taken  by  mouth,  allowing 
the  patient  just  enough  to  wash  out  the  mouth  without  swallowing 
any.    The  thirst  is  relieved  by  saline  enemas. 


234  DIETETICS  FOR  NURSES 

Convalescent  Diet.  —  During  the  fourth  week,  if  the  pain  and 
discomfort  are  decreasing,  soft-cooked  or  creamed  eggs  may  be 
added  to  the  diet,  together  with  thoroughly  boiled  rice,  farina, 
cream  of  wheat,  wheatena  and  other  finely  ground  wheat  foods, 
wine  or  fruit  jelly,  sweetened  slightly,  or  by  using  a  small  amount 
of  saccharine  for  the  purpose,  junket  and  plain  vanilla  ice  cream. 
At  the  end  of  the  fourth  week  a  very  small  portion  of  meat  may  be 
given  once  a  day.  It  may  be  scraped  raw  beef  spread  upon  toast 
or  zwieback,  or  very  lightly  broiled  beefsteak,  broiled  lamb  chop 
or  chicken  (breast  only),  or  boiled  or  broiled  sweetbreads  or  brains. 
Spinach  or  green  peas  pressed  through  a  sieve  are  the  first  vege- 
tables allowed.  After  these  young  tender  carrots  and  st-ring 
beans  may  be  given.  Tea,  coffee,  and  chocolate  are  eliminated 
from  the  diet.  Milk  flavored  with  coffee  or  cocoa  may  serve  as 
a  hot  drink  in  the  morning  when  the  desire  or  need  for  such  a 
drink  is  manifested.  Butter  is  the  best  form  of  fat  to  be  used  in 
eases  of  gastric  ulceration,  but  this  must  be  given  with  the  greatest 
caution.  In  cases  where  this  fat  is  used  in  the  form  of  cream, 
the  amount  must  be  cut  down  or  entirely  abandoned  when  there 
are  evidences  of  butyric  fermentation.  Buttermilk,  koumiss,  and 
other  fermented  milk  drinks  are  often  found  very  satisfactory 
adjuncts  to  the  diet.  These  may  be  given  between  meals,  or  at 
meals  they  may  be  substituted  entirely  for  the  milk  when  other 
foods  are  being  given.  They  are  not  sufiiciently  nourishing  to 
take  the  place  of  the  milk  diet  otherwise.  Albumenized  orange 
juice  and  cream,  egg  and  vichy  may  be  given  to  add  variety  to 
the  diet. 

Anemia.  —  When  anemia  is  severe,  as  is  often  the  case  in 
gastric  ulceration,  the  diet  must  be  reenforced  to  overcome  it. 
Some  of  the  concentrated  milk  foods  such  as  plasmon,  encasin, 
sanatogen,  etc.,  as  well  as  the  predigested  meat  foods,  such  as 
panopepton,  liquid  beef  peptonoids,  and  like  preparations,  may  be 
used  to  reenforce  the  diet. 

Bland  Diet.  —  In  certain  cases  of  gastric  ulceration  it  has  been 
found  more  advisable  to  use  what  is  known  as  a  bland  diet.  This 
consists  of  farinaceous  foods  such  as  farina,  arrowroot,  cream  of 


THE  FEEDING  OF  ADULTS  235 

wheat,  corn  meal,  wheatena,  malted  breakfast  foods  cooked  thor- 
oughly and  given  in  the  form  of  gruels,  and  some  of  the  proprietary 
infant  foods,  such  as  Mellin's  Food,  Eskay's  Food,  Racahout. 
These  foods  may  require  the  addition  of  Taka  diastase  to  make 
them  more  readily  digested.  They  leave  the  stomach  more 
rapidly  than  any  of  the  others,  and  for  this  reason  will  be  found  to 
give  less  discomfort  than  the  foods  containing  a  high  percentage  of 
protein  and  fat.  This  diet,  however,  cannot  be  prolonged  on  ac- 
count of  its  lack  of  balance.  If  the  gruels  are  made  with  milk 
instead  of  with  all  water  they  become  more  evenly  balanced. 
Samples  of  the  stomach  contents  may  be  taken  for  analyses  from 
time  to  time. 

Lavage.  —  When  lavage  is  necessary  the  patient  must  be  allowed 
to  rest  after  the  process  before  being  given  food,  otherwise  it  is 
apt  to  be  vomited. 

Instructions  to  Nurse.  —  The  treatment  for  gastric  ulceration 
is  thus  seen  to  be  strenuous.  In  the  beginning  the  patient  is 
placed  on  a  liquid  or  semi-solid  diet,  or  is  not  fed  at  all  for  a  time. 
This  is  done  that  the  diseased  organ  may  have  a  chance  to  adjust 
itself  as  far  as  possible  and  to  give  the  physician  an  opportunity 
of  studying  the  changes  taking  place  in  that  organ.  During  the 
course  of  the  disease  the  general  symptoms  which  develop  from 
time  to  time,  causing  more  or  less  pain  and  discomfort  to  the 
patient,  are  nervousness,  which  in  some  individuals  amounts  to 
melancholia,  extreme  anemia  and  an  utter  distaste  for  food,  all 
of  which  require  patience  on  the  part  of  the  physician,  the  nurse, 
and  the  patient  herself  to  overcome.  The  nurse  must  see  that  the 
patient  is  not  disturbed  or  made  unhappy  by  having  business  or 
home  cares  talked  over  in  her  presence ;  she  must  be  kept  as  cheer- 
ful and  as  comfortable  as  her  condition  permits  and  urged  to  use 
care  in  her  diet.  After  the  ulcer  is  healed,  to  prevent  a  return  of 
the  trouble  she  must  be  warned  against  eating  too  fast  or  when 
over-tired,  and  she  must  be  advised  against  very  hot  and  highly 
seasoned  foods,  for,  in  the  observance  of  these  simple  common- 
sense  precautions  only  is  she  even  in  a  measure  saved  further 
attacks. 


236  DIETETICS  FOR  NURSES 


GASTRIC   CANCER 


As  a  rule  the  seat  of  the  gastric  cancer  is  the  pylorus.  The 
patient  gives  evidence  of  chronic  gastritis  with  continued  pain, 
localized  tenderness,  vomiting  of  partially  digested  food  and  at 
times  dilation  from  extreme  fermentation.  The  hemorrhages 
are  as  a  rule  not  large,  the  blood  having  changed  to  a  brownish 
color  resembling  coffee  grounds.  Vomiting,  in  cases  where  the 
pylorus  is  involved,  generally  occurs  several  hours  after  eating,  the 
vomitus  being  in  an  advanced  state  of  fermentation.  Upon 
analysis  of  the  stomach  contents  there  is  found  to  be  a  lack  of  free 
HCl. 

Dietetic  Treatment.  —  In  the  dietetic  treatment  of  cancer  of 
the  stomach  the  most  digestible  forms  of  foods  must  be  given, 
milk  forming  in  this,  as  in  other  gastric  disorders,  the  chief  article 
of  diet.  As  too  much  food  cannot  be  tolerated,  the  meals  must  be 
small,  even  if  given  more  frequently.  The  patient  is  often  found 
to  evince  a  distaste  for  meat,  in  which  case  fish  may  be  substituted. 
When  meat  is  given,  it  must  be  simple  in  form  and  preparation, 
such  as  boiled  or  broiled  sweetbreads  or  brains,  scraped  beef  or 
stewed  chicken.  Rice,  farina,  cornmeal  mush,  and  other  fine 
cereals,  cooked  with  or  without  milk,  are  valuable  additions  to  the 
diet.  Well-cooked  and  strained  spinach,  green  peas,  cauliflower, 
carrots,  and  tender  string  beans  and  boiled  or  baked  potatoes  well 
mashed  may  be  recommended.  Tea,  coffee,  or  cocoa  may  be  used 
to  flavor  the  milk.  These  must  be  given  in  small  portions.  The 
following  diet  list  is  recommended  by  Friedenwald  and  Ruhrah  : 

Calories 

8  A.M.  100  grams  of  milk  with  tea 100.0 

30  grams  of  milk  toast 130.0 

10  A.M.  100  grams  of  baked  trout 106.0 

100  grams  of  milk  or  30  grams  panopepton  (57.5)  67.0 

10  grams  of  butter 81.0 

50  grams  of  toast        . 130.0 

50  grams  of  sherry 60.0 


2120. 


THE  FEEDING  OF  ADULTS  237 

Caloriea 

12  M.  Bouillon  with  5  grams  somatose 16.0 

100  grams  of  chicken  or  100  grams  squab  (100)  ] 
or  100  grams  of  calves'  sweetbreads  (90)  I    106.0 

or  100  grams  of  calves'  brains  (140)  J 

60  grams  of  macaroni     .     . 
or  100  grams  of  mashed  potatoes 
or  100  grams  of  spinach  (166) 
or  100  grams  of  asparagus  (18) 

25  grams  of  stale  wheat  bread 65.0 

4  P.M.    20  grams  of  toast 130.0 

20  grams  of  butter 162.0 

40  grams  of  caviar 52.0 

7  p.m.  130  grams  of  milk  (100)  with  5  grams,  somatose  (16)       116.0 

100  grams  of  rice  cooked  in  milk 177.0 

50  grams  of  wheat  bread 130.0 

9  P.M.    30  grams  of  panopepton 57.5 

2024.5 

SUMMAKT 
FACTORS   INDUCING   GASTRIC  DISTURBANCES 

1.  Errors  in  Diet.  —  Overfeeding,  underfeeding,  improper  food, 
unbalanced  diet. 

2.  Disturbed  Secretory  Processes.  —  (a)  Over-  or  under-secre- 
tion  of  gastric  juice. 

(6)  An  excess  or  deficiency  of  hydrochloric  acid  in  the  juices. 

3.  Impaired  Motility  and  Tone  of  the  Gastric  Organ.  —  The 
peristaltic  waves  and  muscular  contraction  of  the  stomach  wall? 
becoming  sluggish  prevent  the  food  mass  from  passing  into  the 
intestines  at  a  normal  rate  of  speed,  thus  giving  rise  to  a  fermen- 
tation of  the  food  and  a  consequent  dilatation  of  the  organ  from  the 
gas  thus  produced. 

Other  Factors.  —  Lack  of  fresh  air  and  exercise,  indoor  occu- 
pation, bad  hygiene,  unsanitary  surroundings,  heredity,  certain 
diseases  which  are  accompanied  by  gastric  disorders. 


238  DIETETICS  FOR  NURSES 

Prophylaxis.  —  Change  mode  of  hving,  take  more  exercise, 
regulate  diet,  prevent  if  possible  the  development  of  gastric  ulcers. 

ACUTE   GASTRITIS 

Absolute  Quiet.  —  In  bed,  when  pain  is  acute  and  temperature 
elevated. 

Treatment.  —  No  food  for  from  twelve  to  thirty-six  hours  or 
more : 

(a)  To  allow  offending  material  to  pass  out  of  the  body ; 

(6)  To  determine  the  cause  of  the  attack ; 

(c)  To  allow  the  inflamed  organ  to  rest. 

Dietetic  Treatment.  —  Fluid  diet  after  period  of  total  ab- 
stinence :  well-strained  fat-free  meat  broths,  albumen  water, 
peptonized  milk.  Whole  milk  in  many  cases  is  to  be  avoided 
on  account  of  the  tough  curd  formation  in  the  stomach ;  in  other 
cases  milk  forms  the  chief  article  of  diet  and  is  modified  or  pep- 
tonized to  meet  the  requirements  of  the  individual. 

Convalescent  Diet.  —  The  diet  is  increased  by  adding  eggs,  soft 
toast,  cereal,  gruels,  rice,  etc.,  later  beefsteak,  lamb  chops,  etc., 
until  the  normal  diet  is  reached. 

Precautions.  —  Patient  warned  against  overeating  or  eating 
foods  known  to  disagree : 

(1)  Because  each  attack  lessens  the  ability  of  the  organ  to  read- 
just itself  to  normal  conditions ; 

(2)  On  account  of  the  danger  of  the  condition  becoming  chronic ; 

(3)  Because  of  the  danger  of  the  development  of  gastric  ulcera- 
tion. 

CHRONIC   GASTRITIS 

Test  Meal.  —  An  analysis  made  of  stomach  contents  after  test 
meal  to  find  the  cause  and  extent  of  the  disorder. 

Treatment.  —  Remove  cause : 

(1)  By  adjusting  the  diet  to  meet  the  needs  superinduced  by  the 
chief  symptom,  namely :  hypersecretion,  or  by  hyposecretion  of 
gastric  juice,  the  acid  content  particularly,  thus  preventing  the 


THE  FEEDING  OF  ADULTS  239 

development  of  ulcers,  and  by  stimulating  or  retarding  the  peri- 
staltic movements  in  the  organ,  as  the  case  may  require ; 
(2)  By  regulating  the  mode  of  living  : 

(a)  Increasing  the  amount  and  kind  of  exercise ; 

(b)  Improving  the  hygienic  and  sanitary  surroundings; 

(c)  Changing,  if  necessary,  the  type  of  occupation. 
Accompanying  Complications.  —  Anemia  due  to  a  prolonged 

interference  with  the  nutrition  of  the  blood-making  tissues ;  ul- 
ceration in  many  cases  caused  by  the  constant  bathing  of  the 
tender  mucous  linings  of  the  stomach  walls  with  a  highly  irritating 
acid  medium  produced  by  a  hypersecretion  of  HCl;  or  to  the 
action  of  bacteria  producing  fermentation  of  carbohydrate  food, 
sugar  in  particular ;  or  to  impaired  motility  which,  by  delaying  the 
passage  of  food  from  the  stomach,  favors  the  development  of 
organic  acids. 

Dietetic  Treatment.  —  Practically  the  same  as  in  acute  gastritis. 
The  simplest  kind  of  foods  only  is  advised ;  articles  known  to  dis- 
agree should  be  avoided;  the  meals  should  be  regular  and  of 
moderate  size.  When  the  chief  symptom  is  hypersecretion  of  acid, 
foods  which  require  more  acid  for  their  digestion,  namely,  the 
proteins,  are  advised,  with  enough  carbohydrates  and  fatty  foods 
to  balance  the  diet.  When  there  is  evidence  of  a  deficiency  in 
HCl,  foods  requiring  less  acid  for  their  digestion  and  those  which 
will  leave  the  stomach  in  the  shortest  possible  time,  namely,  car- 
bohydrate foods,  should  be  given.  These  must  be  judiciously 
selected  on  account  of  their  susceptibility  to  fermentation.  Thus 
the  starches,  rather  than  the  sugars,  are  advised  under  the  circum- 
stances. 

The  Bowels.  —  In  any  gastric  disturbance  it  is  most  essential 
to  keep  the  bowels  open.  Foods  containing  an  appreciable  amount 
of  cellulose  to  increase  their  bulk,  such  as  bran  bread,  prunes,  etc., 
assist  in  this  process.  Certain  fruits,  oranges,  lemons,  and  limes, 
as  well  as  figs  and  raisins,  likewise  exert  a  laxative  effect,  and  for 
this  reason  are  particularly  good  in  many  gastric  disturbances  to 
keep  the  intestinal  tract  free  from  accumulating  food  materials. 


240  DIETETICS  FOR  NURSES 

GASTRIC   ULCERATION 

Test  Meal.  —  As  advised  in  cases  of  chronic  gastritis,  to  deter- 
mine the  cause  of  the  prevaiKng  condition. 
Treatment.  —  Divided  into  three  stages : 

(1)  Hemorrhage  Stage  requires  rest  in  bed,  total  abstinence 
from  food  and  water  for  a  period  varying  from  twenty-four  hours 
to  a  week  or  even  more  in  severe  conditions. 

(a)  Rectal  Feeding.  —  Nutrient  enemas  are  given  when  emacia- 
tion and  anemia  are  pronounced ;  sahne  enemas  are  given  to  reUeve 
thirst  during  period  of  total  abstinence. 

(6)  The  Bowels.  —  It  is  necessary  to  keep  the  bowels  open  to 
keep  the  body  in  good  condition,  a  cleansing  enema  generally 
preceding  the  nutrient  enema  each  morning. 

(2)  Intermediate  Stage.  —  After  the  total  abstinence  treatment. 
Dietetic  Treatment.  —  Fluid  diet ;    milk  is  the  universal  food 

during  this  period  —  it  is  peptonized  or  not  according  to  the 
direction  of  physician. 

Milk  Diet.  —  Peptonized  milk  in  quantities,  beginning  with 
four  ounces  given  every  hour  for  three  or  four  days,  after  which 
the  amount  of  milk  is  increased  to  six  ounces  and  the  intervals 
between  feedings  lengthened  to  two  hours.  This  regime  is  carried 
out  for  from  seven  to  ten  days. 

Reenf orcing  and  Varying  the  Diet.  —  The  monotony  of  milk 
mitigates  its  usefulness ;  in  some  cases  this  may  be  overcome  by 
adding  to  the  dietary  a  cup  of  well-skimmed  meat  broth,  reen- 
forced  by  the  addition  of  an  egg,  once  or  twice  a  day. 

Third  Week.  —  Milk  given  in  form  of  milk  soup,  which  may  be 
thickened  with  rice,  barley  flour,  or  farina.  Meat  extracts  are 
stimulating  to  the  secretory  cells  of  the  stomach,  hence,  in  cases 
accompanied  by  hyperchlorhydria,  it  is  advisable  to  flavor  soups 
sparingly  with  these  extracts.  Water  is  one  of  the  best  known 
stimuli  to  gastric  secretion  and  for  this  reason  the  amount  given  by 
mouth  must  be  limited.  The  mouth  must  be  cleansed  several 
times  a  day,  but  none  of  the  water  swallowed  unless  permitted  by 
the  physician. 


THE  FEEDING   OF  ADULTS  241 

(3)  Convalescent  Stage.  —  During  the  fourth  week,  if  patient's 
condition  warrants  an  increase  in  diet,  the  foods  used  in  acute  and 
chronic  gastritis,  namely,  soft  eggs,  well-cooked  wheat  cereals, 
rice,  soft  toast,  slightly  sweetened  custards,  junket,  and  ice  cream, 
are  given  in  small  quantities.  An  immediate  return  to  the  milk 
diet  must  be  made  if  patient  shows  a  tendency  to  develop  acute 
symptoms. 

Fourth  Week.  —  Meat,  as  advised  in  after-treatment  of  acute 
gastritis ;  the  vegetables,  consisting  of  spinach,  tender  green  peas 
and  beans  and  young  carrots,  must  be  thoroughly  cooked  and 
passed  through  a  sieve  —  a  small  portion  of  one  of  these  vegetables 
to  be  given  once  a  day. 

Fats  in  Gastric  Ulceration.  —  Fats  cause  much  discomfort  in  many 
cases  and  must  be  added  to  the  diet  with  caution,  butter  being  the 
best  form  in  which  to  give  the  necessary  fat  to  balance  the  diet. 

Fermented  Milk.  —  Buttermilk,  koumiss  and  other  forms  of 
fermented  milk  are  particularly  valuable  in  these  cases,  but  can- 
not, on  account  of  their  composition,  be  given  to  the  exclusion  of 
whole  milk. 

Bland  Diet.  —  Farinaceous  foods,  farina,  arrowroot,  cream  of 
wheat,  and  other  j&nely  ground  wheat  and  corn  cereals  made  in 
form  of  gruels. 

Proprietary  Infant  or  Invalid  Foods.  —  These  foods  may  require 
pre-digesting  with  diastase.  This  diet  is  used  for  those  individuals 
showing  an  idiosyncrasy  against  the  milk  diet.  It  cannot  be  pro- 
longed on  account  of  its  lack  of  balance.  It  is  at  times  substituted 
for  the  milk  diet  when  the  case  has  proved  lengthy  and  the  patient 
becomes  tired  of  milk. 

Stomach  analysis  and  urinalysis  are  made  from  time  to  time 
throughout  the  course  of  the  disease. 

GASTRIC   CANCER 

Treatment.  —  Rest  in  bed  when  condition  is  extreme. 

Dietetic  Treatment.  —  Small  meals  given  at  frequent  intervals 
rather  than  the  regulation  three  meals  a  day,  as  the  pressure  from 
the  larger  quantity  of  food  in  the  stomach  causes  discomfort. 


242  DIETETICS  FOR  NURSES 

Milk  in  this  condition,  as  in  other  gastric  disturbances,  forms 
the  chief  article  of  diet.  It  may  be  peptonized  or  modified  if 
necessary. 

Meat  is  often  distasteful  and  cannot  always  be  given.  When 
it  is  included,  it  is  given  in  the  form  of  boiled  or  broiled  sweet- 
breads, brains,  stewed  chicken,  or  scraped  beef.  It  is  often  neces- 
sary to  substitute  fish. 

Convalescent  Diets  used  in  other  gastric  disorders  are  used  for 
patients  having  cancer  of  the  stomach. 

Reenforcing  Agents  are  at  times  valuable.  These  may  consist 
of  some  of  the  prepared  beef  preparations,  such  as  panopepton 
or  somatose.     Milk  gruels  are  also  useful. 

The  free  hydrochloric  acid  content  of  the  stomach  in  such  condi- 
tions is  generally  low  or  lacking  entirely,  consequently  the  food 
mass  is  subject  to  fermentation.  This  is  both  from  the  lack  of  the 
germicidal  quality  of  the  gastric  juice  and  the  impairment  in  the 
motor  process  which  is  almost  an  invariable  accompaniment. 


CHAPTER  XIV 
DISEASES  OF  THE  INTESTINAL  TRACT 

ACUTE  AND  CHRONIC  DIARRHEA  (CATARRH),  ENTEROCOLITIS,  DYS- 
ENTERY, CONSTIPATION,  APPENDICITIS,  CHRONIC  CONSTIPA- 
TION, AUTO-INTOXICATION 

Diarrhea,  like  gastritis,  may  be  a  symptom  of  many  diseases 
and  a  result  of  many  digestional  disturbances.  Enteritis,  entero- 
colitis, dysentery,  typhoid  fever,  and  certain  cases  of  tuberculosis 
and  syphilis  are  all  accompanied  by  an  inflamed  condition  of  the 
mucous  linings  of  the  intestinal  walls,  and  in  each  of  these 
pathological  conditions  we  may  find  diarrhea  as  a  resulting 
symptom. 

Causes.  —  Diarrhea  may  be  acute  or  chronic  in  character.  It 
may  be  brought  on  by  errors  in  diet,  warm  weather,  certain  drugs, 
ptomaines,  bad  hygiene,  polluted  water  or  milk,  and  by  overeating. 
Idiosyncrasies  against  certain  kinds  of  food  have  been  found  in 
both  adults  and  children ;  these  idiosyncrasies  are  manifested  by 
pain  and  diarrhea  whenever  the  offending  foods  have  been  eaten. 
Acute  diarrhea  has  also  been  brought  on  in  children  by  the  drinking 
of  cold  lemonade  when  overheated. 

Diarrhea  in  Children.  —  All  diarrheas  in  children,  and  especially 
those  developing  during  the  hot  months,  must  be  looked  on  with 
suspicion  and  given  immediate  attention  before  they  have  an 
opportunity  to  develop  serious  features  which  may  terminate  in 
death  before  the  seriousness  of  the  condition  is  realized. 

As  a  rule,  almost  any  diarrhea  in  children  will  raise  the  tem- 
perature. This  does  not  occur  so  often  with  adults  unless  the 
diarrhea  results  from  infectious  fevers,  ptomaines,  etc.,  in  which 
case  it  may  rise  suddenly  and  to  a  considerable  height. 

243 


244  DIETETICS  FOR  NURSES 

ACUTE   ENTERITIS    (dIARRHEA) 

The  Bowels.  —  The  symptoms  of  this  condition  are  too  liquid 
or  too  frequent  stools,  the  number  varying  from  three  to  twelve 
or  more  a  day.  They  may  be  greenish  yellow  in  color  and  contain 
particles  of  undigested  food  and  mucus.  In  prolonged  diarrheal 
attacks  the  stools  sometimes  contain  blood. 

The  attack  may  b^  accompanied  by  more  or  less  pain  of  a 
colicky  nature,  due  to  the  formation  of  gas  in  the  intestinal  tract. 
In  ptomaine  poisoning  this  pain  is  sometimes  very  intense.  As  a 
rule  the  intestinal  tract  is  emptied  by  means  of  salts,  oil,  etc.,  but 
this  is  generally  directed  by  the  physician.  A  soapsuds  or  salts 
and  glycerine  enema  to  flush  the  colon  will  often  give  quick 
relief  by  dispelling  the  gas. 

Starvation.  —  The  entire  digestive  tract  requires  absolute  rest 
for  a  certain  period ;  no  food  and  very  little  water,  the  latter  in 
the  form  of  bits  of  ice  only,  are  given  for  a  period  lasting  from 
twelve  to  thirty-six  hours  or  more,  depending  upon  the  violence 
of  the  attack  and  the  condition  of  the  patient.  This  is  to  allow 
the  toxic  substances  which  are  probably  causing  the  disturbance 
to  pass  out  of  the  body,  either  in  the  feces  or  in  the  urine.  When 
the  acute  symptoms  subside,  that  is,  when  the  pain  and  distention 
of  the  intestines  have  disappeared,  and  the  bowel  movements 
become  more  normal  in  number  and  character,  the  dietetic  treat- 
ment suitable  to  the  condition  is  instituted. 

Dietetic  Treatment.  —  The  first  day  the  patient  is  given  a  small 
cup  of  weak  tea,  half  a  glass  of  buttermilk  or  peptonized  milk, 
or  a  cup  of  well-skimmed  meat  broth,  every  three  or  four  hours. 
If  the  patient  is  weak,  the  nourishment  may  be  given  oftener,  and 
in  those  cases  it  is  often  found  advisable  to  give  a  small  amount 
of  alcohol  in  the  form  of  brandy  in  albumen  water,  or  panopepton 
or  liquid  peptonoids.  These  may  be  administered  in  tablespoonful 
doses  every  two  hours.  Whole  milk,  unless  it  is  peptonized,  and 
at  times  even  then,  is  not  advisable  in  diarrheal  conditions  on 
account  of  its  liability  to  form  curds  which  decompose  with  the 
production  of  toxic  substances,  known  to  be  exceedingly  irritating 


DISEASES   OF  THE  INTESTINAL  TRACT        245 

to  the  already  inflamed  mucous  membranes  lining  the  intestinal 
walls. 

Increasing  the  Diet.  —  As  the  diarrhea  and  inflammation  sub- 
side, the  following  foods  are  gradually  introduced  into  the  dietary, 
keeping  in  mind  always  that  a  return  of  the  acute  symptoms  is 
apt  to  occur.  Hence  the  patient  must  never  be  overfed.  It  is 
better  to  err  on  the  side  of  too  little  than  too  much  food  during 
the  early  convalescent  period. 

Diet.  —  Soft-cooked  eggs,  toast  (slightly  buttered),  cocoa  made 
with  water  instead  of  milk,  chicken,  calf's  foot  or  wine  jelly ;  later, 
well-cooked  rice,  junket,  and  soft  custard ;  still  later,  lightly 
broiled  beefsteak,  lamb  chops,  chicken,  squab  or  quail,  sweet- 
breads or  brains.  Not  until  the  patient  is  entirely  free  from  all 
symptoms  of  diarrhea  or  intestinal  disturbance  may  the  following 
foods  be  given  :  cream  or  cream  dishes  such  as  cream  toast,  cream 
chicken,  or  cream  soup,  raw  or  stewed  fruit,  green  vegetables,  salt 
foods,  spiced  foods  of  any  description,  pastries,  confectionery 
and  desserts  in  general,  unless  they  are  simple  in  character  and  are 
sweetened  with  saccharine  instead  of  sugar,  as  the  latter  substance 
is  particularly  susceptible  to  fermentation. 

Anemia  as  a  Result.  — Anemia  is  one  of  the  most  common  results 
of  prolonged  diarrheal  attacks,  especially  in  those  toxic  diarrheas 
resulting  from  infectious  diseases,  dysentery,  etc.  The  blood- 
making  tissues  suffer  from  a  lack  of  nourishment  and  are  in  con- 
sequence incapable  of  producing  blood  of  the  best  quality.  Hence 
the  starvation  treatment  cannot  be  carried  on  over  a  very  extended 
period  or  the  resulting  anemia  may  be  more  difficult  to  overcome 
than  the  original  trouble. 

Selecting  and  Regulating  the  Diet.  —  The  following  points 
must  be  kept  in  view  when  regulating  the  diets  of  individuals  who 
are  prone  to  develop  diarrhea  : 

Preparing  the  Diet.  —  Only  such  foods  as  are  known  to  agree 
with  the  individual,  and  these  prepared  in  the  simplest  manner 
possible,  must  have  a  place  in  the  dietary. 

Fermentation.  —  All  foods  that  are  subject  to  fermentation 
either  in  the  stomach  or  intestines  must  be  withheld,  at  least  until 


246  DIETETICS  FOR  NURSES 

the  attack  is  well  over.  Sugar  is  an  example  of  such  foods; 
saccharine  may  be  substituted  when  necessary. 

Avoidable  Foods.  —  Pork,  veal,  and  shellfish  must  be  left  out 
of  the  dietary,  possibly  for  months,  since  they  have  been  found 
frequently  not  only  to  bring  about  a  return  attack  of  diarrhea  but 
also  to  have  been  the  cause  of  the  original  one. 

Fatty  foods  of  all  sorts  had  best  be  avoided  as  long  as  there  are 
symptoms  of  diarrhea ;  these  foods  are  handled  with  difficulty  by 
the  digestive  apparatus  and  impose  extra  work  upon  the  intestine, 
which  is  already  taxed  by  the  disease. 

Restricting  Fluids.  —  Fluid  foods  should  be  more  or  less  limited 
in  the  diet,  since  they  require  more  effort  on  the  part  of  the  in- 
testines than  the  more  concentrated  foods. 

Proprietary  Foods.  —  Certain  proprietary  infant  foods  ^  are  at 
times  found  to  be  exceedingly  valuable,  since  they  furnish  food  in 
a  concentrated  and  digestible  form.  Among  these  Mellin's  Food, 
Racahout,  and  Imperial  Granum  may  be  mentioned. 

CHRONIC  ENTERITIS 

The  Stools.  —  When  the  diarrhea  is  chronic  in  character,  the 
character  of  the  stools  indicates  the  seat  of  the  inflammation. 
When  there  is  a  great  deal  of  undigested  food  found  in  them 
the  upper  part  of  the  bowel  is  more  affected;  when  the  stools 
contain  more  mucus  than  food  the  lower  bowel  is  the  chief  seat 
of  the  trouble.  The  frequency  and  fluidity  of  the  stools  impose 
a  great  strain  upon  the  entire  body,  causing  a  progressive  emacia- 
tion and  anemia. 

The  treatment  is  similar  to  that  instituted  in  acute  attacks. 
The  starvation  regime  cannot  be  carried  out  for  a  long  period. 
Efforts  must  be  made  to  ascertain  the  cause  of  the  trouble  and  to 
overcome  it.  This  is,  as  a  rule,  more  easily  accomplished  with 
adults  than  with  infants  and  children. 

Dietetic  Treatment.  —  The  diet  is  the  chief  point  of  observation 
and  attention.  The  same  care  must  be  observed  as  is  found 
necessary  in  the  after-treatment  of  acute  diarrhea.     The  patient 

^  Malted  foods  are  contraindicated,  as  malt  exerts  a  very  laxative  effect. 


DISEASES  OF  THE  INTESTINAL  TRACT        247 

must  be  cautioned  not  to  eat  indigestible  foods  or  those  which 
are  known  to  cause  trouble  in  this  respect.  She  must  be  warned 
against  eating  when  over-tired. 

ENTEROCOLITIS 

Enterocolitis  is  an  inflammation  of  the  lower  intestines  and 
colon.  The  stools  contain  more  mucus  than  those  occurring 
when  the  inflammation  is  higher  up  in  the  intestines  and  blood 
is  also  more  frequent  in  these  stools.  The  prostration  is  more 
marked  and  the  fever  apt  to  be  higher  than  in  ordinary  diarrheal 
attacks.  However,  acute  attacks  of  enterocolitis  do  not  pro- 
duce the  marked  anemia  or  the  emaciation  which  are  so  common 
in  the  chronic  cases  of  enteritis. 

Dietetic  treatment  the  same  as  that  used  in  acute  diarrhea. 

ACUTE    DYSENTERY 

Dysentery  is  a  disease  in  which  the  seat  of  inflammation  is  the 
colon.  The  bowels  are  distended  and  tender,  the  pain  at  times 
is  acute  and  spasmodic,  and  the  fever  moderate.  The  constant 
desire  to  defecate  and  the  straining  which  accompanies  each 
effort,  as  well  as  the  small  stools,  containing  both  blood  and  mucus, 
furnish  the  characteristic  symptoms  of  this  disease.  Rest  in  bed 
is  absolutely  necessary;  the  patient  must  be  induced  to  use  a 
bedpan. 

Dietetic  Treatment.  —  The  diet  consists  entirely  of  liquids  as 
in  acute  diarrhea,  the  same  careful  regime  being  observed  as  in 
those  conditions.  The  soreness  in  the  abdomen  is  at  times  re- 
lieved by  spice  poultices  or  a  hot  turpentine  stupe. 

CHRONIC  DYSENTERY 

When  the  above  conditions  become  chronic,  the  patient  loses 
weight  and  strength  rapidly,  becomes  anemic  and  emaciated. 
The  treatment,  like  that  used  in  the  acute  disease,  consists  of  rest 
and  liquid  diet.  The  medicinal  treatment  is  left  entirely  in  the 
hands  of  the  physician. 


248  DIETETICS  FOR  NURSES 


APPENDICITIS 


Appendicitis  is  an  inflammation  of  the  vermiform  appendix. 
It  may  be  acute  or  chronic  in  form. 

Symptoms.  —  The  disease  is  manifested  by  sudden  pain  in  the 
right  side,  tenderness  over  the  seat  of  the  inflammation,  and  a 
locaHzed  rigidity  of  the  right  iliac  fossa.  The  attack  is  as  a  rule 
accompanied  by  fever  which  may  run  as  high  as  103°  or  104°  F. 
The  patient  may  suffer  from  nausea  and  vomiting.  Constipation 
is  generally  an  annoying  symptom  of  the  disease. 

Rest  in  Bed.  —  The  treatment  of  the  acute  attack  consists  of 
total  abstinence  from  food  for  twelve  or  more  hours  until  the  most 
acute  stage  has  passed  and  the  patient  either  passes  into  the 
hands  of  the  surgeon  or  the  symptoms  begin  to  subside  in  violence. 
It  is  necessary  that  the  patient  be  kept  in  bed,  not  being  allowed 
to  rise  for  anything.  The  nurse  must  make  him  understand 
that  his  recovery,  possibly  his  very  life,  depends  upon  his  absolute 
quiet  during  the  early  stages  of  the  disease. 

Dietetic  Treatment.  —  When  the  first  acute  symptoms  have 
passed,  the  diet  must  consist  of  fluids,  well-skimmed  meat  broths, 
buttermilk,  peptonized  milk,  albumen  water  or  albumenized 
orange  juice.  No  solid  food  must  be  given  until  the  acute  symp- 
toms have  disappeared.  When  the  tenderness  in  the  right  side 
has  entirely  left  him  and  he  no  longer  suffers  the  pain  or  nausea, 
a  gradual  return  to  a  normal  diet  may  be  made.  The  patient 
must  be  cautioned  against  eating  indigestible  foods,  as  an  attack 
of  intestinal  indigestion  may  readily  start  up  an  irritation  in  the 
susceptible  appendix  and  cause  a  second  attack  of  appendicitis 
which  is  often  of  a  more  serious  nature  than  the  first. 

Convalescent  Diet.  —  The  return  to  solid  food  is  made  gradually 
as  in  other  intestinal  disorders,  by  giving  the  most  digestible  foods 
first.  Soft  toast,  soft  eggs,  fine  cereal  gruels,  well-cooked  rice, 
well-baked  white  potatoes,  meat,  wine  or  fruit  jellies;  then 
lightly  broiled  beefsteak,  lamb  chop,  chicken,  sweetbreads,  or 
brains  given  in  small  quantities  until  the  intestinal  tract  has 
regained  its  vigor. 


DISEASES  OF  THE  INTESTINAL  TRACT       249 

Foods  to  Be  Avoided.  —  Highly  seasoned  foods  must  be  avoided 
on  account  of  their  astringent  qualities,  which  may  cause  con- 
stipation. Long,  tough-fibered  meats,  coarse  vegetables,  rich 
foods,  in  fact  anything  which  may  cause  intestinal  indigestion, 
must  be  eliminated  from  the  dietary.  A  decomposition  of  the 
foods  lying  in  the  lower  part  of  the  small  intestine  is  dangerous  to 
such  individuals,  since  such  products  are  highly  toxic  in  character 
and  exceedingly  irritating  to  the  already  tender  appendix. 

CHKONIC   CONSTIPATION 

Chronic  constipation  is  so  universal  a  condition  that  it  must 
be  treated  and  overcome  whenever  it  is  possible.  This  condition 
is  not  only  the  cause  but  the  result  of  disease.  It  may  be  induced 
by  improper  food,  poor  hygiene,  sedentary  habits,  lack  of  exercise, 
the  taking  of  drug  preparations  such  as  cough  sirups  which  con- 
tain opium  in  some  form,  the  constant  taking  of  cathartics  and 
enemas,  or  it  may  be  an  hereditary  condition. 

Diet,  Exercise,  and  Fresh  Air.  — The  chief  means  of  overcoming 
this  deplorable  chronic  condition  is  by  regulating  the  diet  and  in- 
creasing the  amount  of  exercise  in  the  fresh  air. 

At  times  it  is  necessary  to  resort  to  artificial  stimulation  of  the 
intestinal  movements;  at  others,  on  account  of  the  disease  of 
which  it  is  only  one  of  the  symptoms,  it  is  dangerous  to  irritate 
the  already  inflamed  mucous  membranes  lining  the  intestinal 
wall.  In  these  cases  the  physician  prescribes  the  method  of 
procedure.  In  ordinary  cases,  however,  the  following  suggestions 
may  be  used  as  a  guide  in  overcoming  the  condition. 

Available  Foods.  —  It  must  be  borne  in  mind  that  the  food  must 
not  be  too  concentrated  in  character  or  it  will  be  so  completely 
absorbed  as  to  leave  little  or  no  residue  for  the  feces,  and  since 
the  waste  products  of  metabolism,  both  of  food  and  body  materials, 
must  be  eliminated,  a  certain  amount  of  fecal  matter  is  necessary 
to  assist  in  this  work.  Vegetables,  such  as  celery,  turnips,  lettuce, 
asparagus,  string  beans,  spinach,  and  beans,  lentils,  lima  beans,  and 
onions ;  fruits,  such  as  raisins,  figs,  and  prunes ;  and  cereals  which 
have  not  had  all  the  bran  removed,  such  as  cut  oats,  cracked  wheat, 


250  DIETETICS   FOR   NURSES 

etc.,  on  account  of  the  cellulose  they  contain,  act  admirably  in 
overcoming  chronic  constipation.  It  is  found,  however,  that  when 
even  these  are  not  sufficient  in  certain  cases,  bran  added  to  the 
food,  either  alone,  with  the  breakfast  cereal,  or  in  the  form  of  bis- 
cuits, muffins,  or  cookies,  will  give  just  the  necessary  amount  of 
ballast  to  the  food  mass  to  make  it  stimulate  the  peristaltic  move- 
ments by  its  pressure  upon  the  intestinal  walls. 

Stimuli  to  Peristalsis.  —  Foods  yielding  certain  acids  exert  a 
stimulating  action  upon  intestinal  peristalsis. 

Available  Foods.  —  Those  particularly  valuable  for  this  purpose 
are  limes,  oranges,  apples,  prunes,  figs,  raisins,  and  most  fruit 
juices  (with  the  exception  of  blackberries,  which  are  constipating) , 
tomatoes,  and  rhubarb.  The  fruit  juices  may  be  diluted  with  water 
or  carbonated  water  (in  the  latter  case  the  action  is  increased  be- 
cause of  the  gas  contained  in  the  water),  and  taken  the  first  thing  in 
the  morning,  or  the  fruit  may  be  eaten  at  night  before  retiring,  and 
in  the  morning  on  an  empty  stomach.  Prune  pulp  or  prune 
jelly  may  be  given  to  children  as  well  as  to  adults.  The  action  of 
this  fruit  is  augmented  by  the  addition  of  senna  leaves.^  A  con- 
serve made  of  prunes,  figs,  and  raisins  given  in  teaspoonful  doses 
at  night  and  before  breakfast  often  gives  splendid  results  in 
curing  chronic  constipation. 

Gas-forming  Foods.  —  The  eating  of  foods  which  give  rise  to  a 
slight  formation  of  gas  owing  to  their  tendency  to  ferment  like- 
wise acts  as  a  stimulus  to  intestinal  movements.  Among  these 
may  be  mentioned  honey,  molasses,  cauliflower,  cabbage,  spinach, 
and  onions.  If  the  honey  and  molasses  are  poured  on  bran  muffins 
or  biscuits,  on  breakfast  food,  or  added  as  sweetening  agents  to 
cookies,  they  will  be  found  particularly  valuable.  Care  must 
be  taken,  however,  not  to  give  too  much  of  either  of  these  foods 
or  they  will  disturb  the  digestion  and  do  more  harm  than  good. 

Use  of  Salt  Foods.  —  Foods  such  as  herring,  caviar,  anchovies, 
ham,  etc.,  on  account  of  the  salt  they  contain,  exert  a  stimulating 
effect  upon  the  movements  in  the  small  and  large  intestines. 
Graham  bread,  spread  with  brown  sugar,  molasses,  or  honey,  makes 

2  See  Formula  at  end  of  chapter. 


DISEASES   OF  THE  INTESTINAL  TRACT        251 

an  acceptable  addition  to  the  meal  of  the  majority  of  children  and 
to  that  of  many  adults. 

Fats  and  Mineral  Oils.  —  The  use  of  fats  is  often  recommended ; 
olive  oil  may  be  given  in  tablespoonful  doses  before  breakfast  and 
at  night  or  it  may  be  served  on  vegetables  and  salads.  If  one  or 
two  tablespoonfuls  are  taken  at  night  and  before  breakfast,  it  may 
act  as  a  laxative.  In  many  cases,  however,  this  oil  is  completely 
absorbed  in  the  small  intestine  and  hence  there  is  none  left  to 
lubricate  the  passage  for  the  food  mass.  When  vegetable  oils 
do  not  prove  satisfactory,  mineral  oils  may  be  substituted.  These 
oils  have  absolutely  no  fuel  value  and  are  not  digested  in  the 
intestinal  canal  but  mix  with  the  fecal  mass,  softening  it  and 
stimulating  its  passage  through  the  large  intestine.  There  are 
certain  individuals  with  whom  the  mineral  oils  do  not  act  as 
lubricants  and  instead  of  softening  the  feces  and  lubricating  the 
passage  will  slip  through  the  intestinal  canal  without  carrying  the 
feces  along. 

Sample  Diet  Sheets.  —  The  following  menus  are  suggested  for 
the  use  of  individuals  suffering  with  chronic  constipation ; 

7  A.M.  Orange  juice  and  water. 

8  A.M.  1  bran  muflSn  with  honey  and  cream. 

1  or  2  slices  of  bacon. 
Whole  wheat  biscuits. 
A  cup  of  coffee,  cereal  coffee,  or  hot  milk  (not  boiled). 

Luncheon 

1  P.M.  Casserole  of  beef  made  with  lean  beef. 
Turnips  and  potatoes. 

Graham  bread  or  muffins  and  honey  or  preserves. 
Milk  or  "  hot  water  "  tea. 

Dinner 

Tomato  bouillon. 
Roast  lamb. 
String  beans. 


252  DIETETICS  FOR  NURSES 

Potatoes  baked  with  jackets  on. 

Celery  salad,  dressed  with  plenty  of  oil  and  lemon  juice. 

Prune  jelly  with  whipped  cream. 

Breakfast 

Prunes  and  figs  cooked  together. 

Slice  of  ham  with  1  soft-cooked,  poached,  or  scrambled  egg. 

Whole  wheat  or  bran  biscuits. 

Coffee  with  cream  and  sugar. 

Luncheon 
Vegetable  soup. 
Pork  and  beans. 
Boston  brown  bread. 
Baked  apple  (skin  eaten). 
Oatmeal  wafers. 

Dinner 
Roast  beef. 

Spinach  or  cauliflower  served  with  butter  sauce. 
Cold  slaw. 

Pineapple  jelly  (pineapple  left  in),  whipped  cream,  or 
Date  and  fig  pudding. 

AUTO-INTOXICATION 

Auto-intoxication  is  a  condition  produced  by  the  absorption  of 
the  decomposition  products  of  food  in  the  intestinal  canal. 

Absorption  of  Toxins.  —  As  a  rule  the  condition  occurs  in  in- 
dividuals suffering  more  or  less  from  constipation  which  may  be 
due  to  errors  in  diet  or  a  lack  of  tone  in  the  intestines,  giving  rise 
to  a  sluggishness  in  the  peristaltic  movements  in  this  region  of  the 
alimentary  canal.  In  certain  individuals  the  liver  is  more  or  less 
sluggish,  or  in  some  way  fails  to  do  its  regular  work  of  detoxifying 
the  products  of  metabolism  brought  in  by  the  blood  stream,  in 
which  case  these  toxins  are  reabsorbed  into  the  system  and  induce 
a  condition  known  as  auto-intoxication. 


DISEASES  OF  THE  INTESTINAL  TRACT       253 

Care  of  Bowels.  —  As  a  rule  the  patient  has  more  or  less  fever, 
nausea  and  at  times  vomiting.  The  head  aches  and  the  abdomen 
may  be  distended  by  the  formation  of  gas  in  the  intestines.  The 
treatment  is  like  that  used  in  the  majority  of  intestinal  disorders. 
The  bowels  are  emptied  by  means  of  soapsuds  or  salts  and  glyc- 
erine enemas.  Certain  physicians  recommend  an  enema  made 
with  equal  quantities  of  milk  and  molasses,  with  enough  hot 
water  added  to  make  a  thin,  warm  solution.  Care  must  be  used 
in  preparing  this  flatus  enema  on  account  of  the  danger  of  curdling 
the  milk  with  the  acid  in  the  molasses  and  the  hot  water.  If  the 
solution  should  cm-die  it  must  be  discarded  and  a  fresh  solution 
prepared.  A  flatus  enema  containing  salts,  glycerine,  and  a  few 
drops  of  turpentine  is  also  valuable  in  removing  the  gas  formed  by 
the  action  of  the  putrefactive  bacteria  upon  the  unabsorbed  food 
mass.  This  enema  must  be  given  '*  high  "  so  as  to  reach  the  spot 
in  the  colon  where  it  may  eflSciently  do  its  work. 

Dietetic  Treatment.  —  The  diet  may  consist  of  fluids  for  the  first 
few  days,  or  as  long  as  the  fever  continues.  Buttermilk  is  probably 
the  best  fluid  food  to  use  under  such  conditions,  since  it  not  only 
nourishes,  but  likewise  furnishes  lactic  acid  bacteria  which  aid  in 
the  destruction  of  the  more  harmful  bacteria,  especially  numerous 
under  the  conditions  just  mentioned.  When  whole  milk  is  given  it 
is  best  to  peptonize  it.  Well-strained  meat  broths  may  be  given 
occasionally  to  vary  the  diet  and  albumenized  orange  juice  or 
orange  juice  in  carbonated  water  may  also  be  given  once  or  twice 
daily  during  the  febrile  period.  After  this,  the  patient  may  have 
well-cooked  cereal  gruels.  These  may  be  dextrinized  with  vege- 
table diastase  (Taka  diastase)  if  necessary.  A  return  to  normal 
diet  is  made  gradually  to  prevent  a  return  of  the  trouble.  The 
patient  should  be  advised  against  overeating,  and  eating  highly 
seasoned  or  indigestible  foods. 

Convalescent  Diet.  —  The  diets  recommended  for  use  during 
convalescence  from  other  intestinal  disorders  may  serve  here, 
reducing,  however,  the  allowance  of  meat,  since  meat  proteins 
are  particularly  susceptible  to  attacks  of  putrefactive  bacteria 

Dietary  Precautions.  —  After  the  body  has  returned  to   its 


254  DIETETICS  FOR  NURSES 

normal  state,  the  patient  must  keep  in  mind  the  danger  arising 
from  constipation  and  intestinal  putrefaction.  The  following  menu 
is  given  as  a  guide  to  aid  the  individual  in  selecting  a  diet  which 
will  in  a  measure  assist  in  preventing  future  attacks  of  intestinal 
putrefaction  and  auto-intoxication : 

7  A.M.  1  glass  of  water  with  orange  or  lime  juice. 

Breakfast 

8  A.M.  Stewed  prunes  or  figs. 

Cereal  and  cream. 
Buttered  toast. 
Crisp  bacon. 
Coffee. 

Luncheon 

Vegetable  or  tomato  soup. 

Green  vegetables  such  as  cauliflower,  greens,  or  tomatoes ;  or 

Baked  dishes  such  as  macaroni  and  cheese,  scalloped  maca- 
roni and  tomatoes ;  or 

Baked  potatoes  or  potatoes  au  gratin  or  stuffed  tomatoes 
with  rice. 

Stewed  fruit  or  fruit  jelly. 

Sponge  cake  with  simple  sauce. 

Junket. 

Toasted  crackers  or  bread. 

Dinner 
Milk  soup. 

Cream  of  spinach,  celery,  peas,  or  tomatoes. 
Baked  eggs,  cheese  souffle  or  nut  loaf. 
Tender  green  peas,  cauliflower,  spinach,  boiled  or  creamed 

potatoes,  well-boiled  rice. 
Fruit,  vegetable,  tomato,  or  cheese  salad. 
Simple  dessert,  such  as  cottage  pudding  with  simple  sauce, 

fruit  pudding,  prune  whip,  or  frozen  desserts :  ice  cream 

or  water  ices  ;  or 
Cheese  and  crackers. 
Coffee. 


DISEASES  OF  THE  INTESTINAL  TRACT       255 

SUMMARY 
DIARRHEA 

Character.  —  Acute  or  chronic,  accompanying  many  pathological 
conditions,  especially  in  children  in  whom  diarrhea  in  any  form 
must  be  given  immediate  attention. 

Causes.  —  Errors  in  diet,  polluted  water  or  milk,  ptomaines, 
bad  hygiene,  and  certain  drugs. 

Bowels.  —  The  stools  vary  in  number  from  three  to  twelve  a 
day.  They  may  be  greenish  yellow  in  color,  containing  mucus 
and  particles  of  -  undigested  food  and,  in  prolonged  cases, 
blood. 

Treatment.  —  Rest  in  bed  and  total  abstinence  from  food  for 
from  twenty-four  to  forty-eight  hours.  Salines  are  usually  given 
by  mouth  or  by  rectum,  but  this  is  left  to  the  discretion  of  the 
physician.  Very  little  water  is  given  by  mouth  during  the  period 
of  total  abstinence.  Thirst  is  relieved  by  bits  of  ice,  and  enemas 
are  given  if  necessary. 

Administration  of  Diet.  —  When  acute  symptoms  have  dis- 
appeared and  the  stools  are  becoming  more  normal  in  character 
and  number,  a  fluid  diet  of  from  four  to  six  ounces  is  administered 
every  three  or  four  hours  or  oftener  if  patient  is  very  weak. 
Brandy  may  likewise  be  given  in  cases  in  which  exhaustion  is 
marked. 

Dietetic  Treatment.  —  Concentrated  foods  of  the  simplest  char- 
acter and  only  those  known  to  agree.  Proprietary  infant  or 
invalid  foods,  except  malted  foods,  which  exert  a  laxative  effect ; 
among  those  found  to  be  good  may  be  mentioned  Mellin's  Food, 
Imperial  Granum,  and  Racahout. 

Foods  to  Be  Avoided.  —  Fatty  foods ;  pork,  veal,  and  shellfish ; 
all  foods  that  are  subject  to  fermentation  in  the  stomach  or  in- 
testinal tract  (sugar). 

Foods  to  Be  Limited.  —  Fluids,  soup,  beverages,  etc.,  because 
they  impose  more  work  on  the  intestines. 


256  DIETETICS  FOR  NURSES 

ENTEROCOLITIS 

Seat  of  Inflammation.  —  Lower  intestine  and  colon. 

Differentiating  Characteristics.  —  More  mucus  and  blood  in 
stools ;  greater  prostration ;  greater  rise  of  temperature ;  and  less 
anemia  than  in  chronic  enteritis. 

Dietetic  Treatment.  —  Practically  the  same  as  in  other  diarrheas. 

DYSENTERY 

Characteristic  Symptoms.  —  Acute  and  spasmodic  pain,  tender- 
ness and  distention  in  the  bowels,  moderate  fever,  straining  and  a 
constant  desire  to  defecate,  small  stools  containing  blood  and 
mucus,  loss  of  weight  and  marked  anemia  when  condition  becomes 
chronic. 

Treatment.  — Rest  in  bed  absolutely  necessary;  the  use  of  the 
bedpan  made  obligatory;  soreness  relieved  by  hot  turpentine 
stupes  or  spice  poultices. 

Dietetic  Treatment.  —  No  food  for  a  period  of  from  thirty-six 
to  forty-eight  hours,  after  which  fluids  and  the  regime  recommended 
in  acute  diarrhea  are  advisable.  In  chronic  dysentery  the  diet  is 
practically  the  same.  The  extreme  exhaustion  and  anemia  accom- 
panying these  conditions  make  it  necessary  to  increase  the  diet 
carefully  but  soon  to  offset  as  far  as  possible  the  devastating  effects 
of  the  disease. 

APPENDICITIS 

Treatment.  —  Confinement  to  bed  is  absolutely  necessary  while 
acute  symptoms  prevail.  The  life  of  the  patient  may  depend  upon 
the  care  with  which  this  "  quiet  "  period  is  carried  out.  No  food 
should  be  given  for  twelve  or  more  hours  to  enable  the  physician 
to  make  a  proper  diagnosis  and  to  allow  the  intestinal  tract  and 
appendix  complete  rest  from  the  irritating  effects  of  food  passing 
down  the  canal. 

Dietetic  Treatment.  —  Acute  Stage :  Total  abstinence  for  a 
period,  after  which  fluids  as  given  in  other  acute  intestinal  dis- 
orders. No  solid  food  until  acute  symptoms  have  subsided  ;  then 
a  gradual  return  to  normal. 


DISEASES  OF  THE  INTESTINAL  TRACT        257 

Convalescence :  When  tenderness  in  right  side  has  disap- 
peared, the  return  to  a  normal  diet  is  made  gradually.  Gelatine, 
soft  eggs,  soft  toast,  fine  cereal  gruels,  well-cooked  rice,  well-baked 
white  potatoes,  tender  rare  beefsteak  or  lamb  chops,  the  breast 
of  chicken,  sweetbreads,  and  brains  are  recommended. 

Relapse  or  Recurring  Appendicitis.  —  The  patient  must  be 
warned  against  eating  indigestible  foods  or  any  kind  of  foods  liable 
to  cause  constipation;  also  against  overeating  or  eating  when 
over-heated  or  over-tired.  One  attack  predisposes  to  another, 
hence  the  above  precautions  are  necessary  to  prevent  the  condition 
from  becoming  chronic. 

CHRONIC   CONSTIPATION 

Causes.  —  Improper  foods,  indoor  occupations  leading  to  a  lack 
of  fresh  air  and  exercise,  bad  hygiene,  certain  drugs,  such  as  cough 
sirups,  etc.,  containing  opium  in  some  form,  constant  use  of 
cathartics  and  enemas  to  move  the  bowels,  heredity. 

Dietetic  Treatment :  Foods  to  Be  Avoided.  —  Highly  spiced 
foods  must  be  avoided  on  account  of  their  astringent  qualities, 
too  concentrated  foods  because  they  fail  to  furnish  the  necessary 
bulk  without  which  the  waste  matter  cannot  pass  out  of  the  body 
at  a  sufiicient  rate  of  speed  to  prevent  putrification  taking  place 
in  the  intestinal  tract. 

Foods  Stimulating  Peristalsis  on  account  of  their  bulk :  Bulky 
foods,  such  as  vegetables,  cabbage,  turnips,  cucumbers,  spinach, 
beans,  celery,  lettuce,  etc. ;  cereal  foods  containing  a  high  percentage 
of  bran,  bran  bread  and  cookies,  fruits  such  as  raisins,  prunes,  figs. 

Foods  Acting  as  Stimuli  to  Intestinal  Movements  on  account 
of  their  acid  content :  Limes,  oranges,  apples,  prunes,  figs,  raisins, 
most  fruit  juices  (blackberries  excepted),  rhubarb,  tomatoes, 
cauliflower,  spinach,  onions,  honey,  and  molasses ;  senna  leaves 
likewise  have  a  distinct  action  upon  the  peristaltic  movement  of 
the  intestines,  hence  are  included  here. 

Precautions.  —  Emphasis  should  be  placed  upon  the  dangers  of 
(1)  overeating  any  of  the  foods  indicated  in  the  above  list  and  thus 
bringing  about  conditions  more  dangerous  in  result  than  the  original 


258  DIETETICS  FOR  NURSES 

disturbance ;  (2)  the  taking  of  drugs  to  move  bowels  on  account 
of  the  ease  with  which  the  habit  is  acquired  and  the  consequent 
inabiHty  of  the  bowels  to  move  without  such  whips ;  (3)  the  taking 
of  too  little  water,  thereby  allowing  a  too  concentrated  condition 
of  the  food  mass  and  a  consequent  accumulation  of  substances 
which  inhibit  peristaltic  action. 

Use  of  Fats  and  Mineral  Oils.  —  Olive  and  other  vegetable  oils, 
if  not  completely  absorbed,  are  advised  on  account  of  their  lubri- 
cating effects.  The  same  can  be  said  of  the  mineral  oils  which 
have  no  food  value  but  in  many  cases  furnish  the  lubricant  neces- 
sary in  certain  individuals  suffering  from  sluggish  intestinal 
peristalsis. 

formulas  valuable  in  combating  chronic  constipation 

Prunes 

Prunes  should  be  cooked  slowly,  the  sugar  added  after  the  fruit 
has  cooked  for  an  hour  or  more.  One  ounce  of  senna  leaves 
added  to  a  pound  of  prunes  will  increase  the  laxative  effect  of  the 
fruit. 

Prune  Pulp 

8  prunes;  enough  water  to  cover;  1  teaspoonful  of  senna 
leaves ;  soak  prunes  for  several  hours  or  overnight.  Cook  for  two 
hours,  very  slowly;  add  senna  leaves  and  cook  1  hour  or  more. 
Lift  the  prunes  from  the  juice,  remove  pits ;  press  through  a  sieve ; 
if  not  sufficiently  sweet,  add  more  sugar.  Stir  in  enough  of  the 
juice  to  make  the  pulp  soft.  This  may  be  served  with  cream 
or  beaten  into  one  well-beaten  egg  white. 

Prune  Jelly 

8  prunes          '  2  tsp.  lemon  juice  or  a  few  drops  of  vanilla 

1  tsp.  senna  leaves  2  tsp.  granulated  gelatine  soaked  in  2  tbs. 

1  pt.  water  water. 

2  tbs.  or  more  sugar 

Cook  prunes  until  tender,  adding  the  senna  leaves  the  last  hour. 
Strain  juice  and  add  enough  hot  water  to  make  cupful  if  there  is 


DISEASES  OF  THE  INTESTINAL  TRACT         259 

not  that  quantity  left  after  cooking  the  prunes.  Sweeten  juice, 
add  lemon  juice  and  gelatine;  return  to  fire;  allow  to  boil  up; 
strain  into  a  glass  bowl  and  place  on  ice. 

Prunes  and  Figs 

I  lb.  each  prunes  and  dried  figs 
1  oz.  senna  leaves 

Boil  from  2  to  3  hours  as  directed  in  preparing  prunes  as  above. 
Lift  fruit  from  hot  sirup,  place  in  quart  jar,  strain  the  juice  and 
pour  over  the  fruit.     Use  as  needed. 

Conserve 

f  lb.  prunes  (pits  removed)     ^  lb.  figs 

J  lb.  raisins  (seeded)  1  oz.  senna  leaves 

Boil  prunes  just  enough  to  allow  of  the  pits  being  removed.  Cool 
and  pass  with  the  senna  leaves,  figs  and  raisins  through  the  food 
chopper.  After  passing  through  once  return  to  chopper  and  pass 
through  a  second  time.  See  that  the  senna  leaves  and  fruit  are 
thoroughly  mixed  and  finely  chopped.  Place  in  a  quart  jar  and 
give  in  doses  of  from  1  to  2  teaspoonfuls  night  and  morning. 

Bran  Muffins  or  Gems 

1^  cups  bran  |  tsp.  soda 

2  tbs.  molasses        J  cup  milk 
I  tsp.  salt  1  egg 

Sift  soda  and  salt  into  bran  ;  stir  milk  into  molasses  and  add  to 
bran.  Mix  in  the  milk,  beaten  egg.  Bake  in  greased  muffin 
pans. 

Bran  Gems 

H  cups  bran  2  tbs.  melted  butter 

1  tbs.  sugar  1  tsp.  baking  powder 

1  egg  1  tsp.  salt 

Mix  and  bake  in  six  greased  gem  pans. 


260  DIETETICS  FOR  NURSES 

Bran  Gems 

1  cup  bran  1  cup  milk 
1|  cups  wheat  flour       1  egg 

2  tbs.  butter  or  lard      6  prunes  ^ 

1  tsp.  salt 

Mix  thoroughly.  Pour  the  gem  pans  half  full ;  place  a  large 
prune  in  center  of  each.     Fill  cup  with  batter  and  bake. 

Bran  Cookies 

J  cup  wheat  flour  1  tsp.  cinnamon 

1  cup  bran  J  tsp.  nutmeg 

J  cup  molasses  »  |  tsp.  cloves 

J  cup  milk  2  eggs 

J  cup  butter  (or  butter  and  lard  mixed)  J  tsp.  salt 

Cream  butter  and  sugar  together,  sift  salt  and  spices  into  the 
flour  and  bran.  Add  eggs  and  milk  to  sugar  and  butter,  beat 
into  the  bran  mixture.  Drop  from  spoon  on  to  a  well-greased 
paper.     Bake  in  a  quick  oven. 

Oatmeal  Cookies 

2  cups  flour  2  tsp.  butter,  lard,  or  Crisco 

J  cup  sugar  1  cup  seeded  raisins 

J  cup  milk  1  egg 

J  cup  oatmeal  |  cup  shelled  peanuts 

Mix  shortening  and  sugar  together.  Mix  oatmeal  and  peanuts 
(broken  into  small  pieces)  into  the  flour.  Add  milk  and  well- 
beaten  egg,  then  the  raisins;  mix  into  a  dough,  roll  into  a  thin 
sheet,  and  cut  into  small  cakes.     Bake  in  quick  oven. 

3  The  prunes  must  be  cooked  until  tender,  not  soft,  before  placing  in  mufl&ns. 


CHAPTER  XV    ^ 
TYPHOID  FEVER 

Definition.  —  Typhoid  fever  is  an  acute  infectious  disease 
excited  by  specific  bacteria  (Eberth).  The  intestines  become  the 
seat  of  ulceration  (Peyer's  patches),  which  at  times  perforate. 
The  chief  symptoms  of  the  disease  are  fever,  headache,  abdbminal 
distention  and  tenderness,  more  or  less  diarrhea  and  a  rose- 
colored  abdominal  rash.  The  source  of  infection  is  found  in  the 
intestinal  contents  of  a  typhoid  fever  patient,  which  in  some  way 
come  in  contact  with  and  infect  drinking  water,  milk,  etc. 

Energy  Expenditures  in  Febrile  Conditions.  —  In  febrile  condi- 
tions the  energy  expenditures  increase  as  much  as  twenty-five 
per  cent  in  some  cases,  and  when  bacterial  activity  is  added  to 
this,  as  is  the  case  in  typhoid  fever,  the  tissue  waste  becomes 
correspondingly  greater;  hence  the  nutrition  assumes  the  chief 
role  in  such  cases,  for  in  no  other  way  can  the  tissue  waste  and 
energy  expenditure  be  met  and  overcome. 

Energy  Expenditures  in  Typhoid.  —  In  typhoid  fever  the 
problem  of  meeting  these  expenditures,  and  at  the  same  time 
protecting  the  heart  and  kidneys  from  the  abnormal  strain  placed 
upon  them  in  handling  the  toxic  substances  produced  as  the  result 
of  bacterial  action  in  the  intestines,  becomes  very  real.  It  requires 
eternal  vigilance  and  patience  not  only  from  the  physician  but 
especially  from  the  nurse,  with  whom  so  much  responsibility  rests. 
The  dietetic  treatment  necessarily  is  the  principal  point  to  which 
all  efforts  must  be  directed.  By  this  is  understood  not  only  the 
type  and  amount  of  food  given  the  patient,  but  the  behavior  of 
this  food  in  the  body  as  manifested  by  the  symptoms,  namely, 
the  appearance  of  the  patient,  the  condition  of  the  mouth,  the 
abdominal  distention,  tenderness,  diarrhea,  nausea,  and  vomiting, 
the  hemorrhage  which  at  times  occurs  in  spite  of  all  care,  and 

261 


262  DIETETICS  FOR  NURSES 

perforation  which  sometimes  results  in  death,  and  acidosis  or 
acetonuria.  All  of  which  makes  this  disease  one  requiring  the 
most  efficient  attention  from  a  nutritional  standpoint. 

Energy  Requirements  in  Tjrphoid  Fever.  —  In  a  previous  chapter 
the  energy  expenditures  of  the  normal  individual  were  dealt  with ; 
it  was  seen  that  a  man  at  rest,  that  is,  in  bed,  not  rising  for  any- 
thing, had  a  normal  expenditure  of  energy  requiring  from  1900  to 
2200  calories  per  day.  Now,  if  these  expenditures  were  increased 
twenty-five  per  cent  by  the  fever  and  still  more  by  the  bacterial 
activities,  it  is  clearly  seen  that  the  diet  must  be  increased  in  pro- 
portion if  the  tissue  waste  is  to  be  prevented  and  the  normal 
body  weight  of  the  patient  maintained. 

High  Calorie  Diet.  —  Dr.  Warren  Coleman,^  to  whom  we  owe 
so  much  for  his  pioneer  work  in  feeding  in  typhoid  fever,  devised 
the  so-called  "  High  Calorie  Diet."  This  consists  of  foods  of  the 
most  digestible  type  prepared  in  the  simplest  way.  The  weight 
of  the  patient  is  considered  and  the  diet  directed  with  the  following 
points  in  view  :  (1)  to  cover  the  energy  requirements  of  the  body ; 
(2)  to  make  good  the  tissue  waste  which  at  times  amounts  to  a 
loss  of  from  15  to  20  grams  of  nitrogen  a  day  (or  from  J  to  f  pound 
of  muscle) ;  ^  (3)  to  check  or  prevent  the  development  of  serious 
complications,  kidney,  heart,  etc. 

In,  the  Metabolism  Ward  at  Belle vue  Hospital,  New  York,^ 
the  best  results  are  obtained  by  the  giving  of  diets  furnishing  from 
60  to  80  calories  per  kilogram  per  day,  or  from  4000  to  5500 
calories. 

Fluid  Diet.  —  It  is  clearly  seen  that  it  would  be  practically 
impossible  to  obtain  a  sufficient  number  of  calories  by  using  milk 
alone  or  even  a  mixed  fluid  diet  to  supply  the  above  requirements. 
Since  milk  alone  in  such  a  diet  would  probably  cause  such  dis- 
comfort as  to  make  it  unwise  to  continue  it,  the  ideal  diet  would 

1  Warren  Coleman,  Cornell  University  Medical  College,  Visiting  Physician,  Belle- 
vue  Hospital,  New  York  City. 

'  "Diet  in  Typhoid  Fever,"  by  Warren  Coleman,  "Journal  of  American  Medical 
Association,"  Oct.  9,  1909,  Vol.  LIII. 

'"Diet  in  Typhoid  Fever,"  by  Warren  Coleman,  reprint  from  "Journal  of 
American  Medical  Association,"  June  9,  1909. 


TYPHOID  FEVER  263 

seem  to  be  one  in  which  the  fats,  proteins  and  carbohydrates  are 
furnished  in  a  semi-soUd  or  solid  form,  together  with  a  sufficient 
amount  of  liquids  to  prevent  too  great  concentration  in  the  food, 
to  relieve  thirst,  and  to  act  as  a  carrier  of  reenforcing  substances, 
such  as  lactose,  eggs,  casein  products,  etc. 

Absorption  Food.  —  The  question  as  to  whether  the  food  is 
absorbed  when  given  to  typhoid  fever  patients  has  often  been  asked. 
That  it  is  has  been  proved  in  the  series  of  calorimeter  experiments 
conducted  in  the  Metabolism  Ward,  Bellevue  Hospital.^  Here  it 
was  demonstrated  that  under  the  high  calorie  diet  the  patient 
consumed  large  amounts  of  food  with  relish  and  that  which  was 
not  utilized  by  the  organism  immediately  was  stored  for  future 
needs. 

Diarrhea  and  Tympanites.  —  Constant  attention  and  study 
of  various  typhoid  patients  taking  a  maximum  amount  of  food  a 
day  has  proved  that  the  diarrhea  and  tympanites  which  at  times 
occur  in  these  as  well  as  other  cases  are  due  to  too  much  of  one  or 
another  of  the  food  constituents  rather  than  to  the  general  amount 
of  the  diet.  Diarrhea  may  then  be  traced  to  an  excess  of  cream, 
and  the  tympanites  to  an  excess  of  lactose,  and  a  reconstruction 
of  the  dietary  will  often  obviate  the  trouble. 

Increasing  the  Diet.  —  It  is  always  advisable  to  "go  slow  "  in 
adding  new  foods  to  the  diet;  milk,  cream,  eggs  and  lactose  are 
the  principal  articles  constituting  the  diet.  To  this  are  added 
fine  cereal  gruels,  well-cooked  rice,  rice  custard,  tapioca  custard, 
junket,  ice  cream,  wine  or  fruit  jellies,  toast,  eggs  (soft  cooked, 
poached,  creamed,  or  raw,  in  milk),  or  fruit  beverages,  cocoa,  but- 
termilk, koumiss,  certain  proprietary  infant  foods  such  as  Mellin's 
Food,  Eskay's  Food,  Racahout  and  malted  milk,  with  a  well- 
baked  potato,  milk,  cream  or  buttered  toast  added  as  the  condi- 
tion and  appetite  warrant. 

Milk  Diet.  —  The  following  milk  diets  ^  were  devised  by  Dr. 
Coleman  to  be  given  in  certain  cases  of  typhoid  fever  during  the 

*  Determined  by  calorimeter  observation  from  the  Russell  Sage  Institute  of 
Pathology  in  affiliation  with  the  Medical  Division  of  Bellevue  Hospital,  under 
Warren  Coleman  and  Eugene  DuBois. 

6  "American  Journal  of  Medical  Sciences,"  January,  1912,  by  Warren  Coleman. 


264  DIETETICS  FOR  NURSES 

acute  stage.     These  formulas  consist  of  milk,  cream  and  lactose 
and  furnish  from  1000  to  3000  calories  per  day.   > 

Calories 
1000  calories  per  day  — 

Milk,  1000  CO.  (1  qt.)  700 

Cream,  50  c.c.  (If  oz.)         100 

Lactose,  50  gm.  (If  oz.) 200 

This  furnishes  eight  feedings,  each  containing 

Milk,  120  c.c.  (4  oz.) 80 

Cream,  8  gm.  (2  dr.) 15 

Lactose,  6  gm.  (1|  dr.) 24 

2000  calories  per  day  — • 

Milk,  1500  c.c.  (U  qt.)       1000 

Cream,  240  c.c.  (8  oz.)         500 

Lactose,  125  gm.  (4  oz.) 500 

This  furnishes  seven  feedings,  each  containing 

Milk,  210  c.c.  (7  oz.) 140 

Cream,  30  c.c.  (1  oz.) ' 60 

Lactose,  18  gm.  (4|  dr.) 72 

3000  calories  per  day  — 

Milk,  1500  c.c.  (U  qt.)        1000 

Cream,  480  c.c.  (1  pt.)        2000 

Lactose,  250  gm.  (8  oz.) 1000 

This  furnishes  eight  feedings,  each  containing 

Milk,  180  c.c.  (6  oz.) 120 

Cream,  60  c.c.  (2  oz.) 120 

Lactose,  30  gm.  (1  oz.) 120 

Varying  the  Diet.  —  It  has  been  found  possible,  even  advisable, 
to  vary  the  above  diets  in  many  cases.  The  disease  extends  over 
such  a  long  period  that  if  a  fluid  diet  is  adhered  to  the  patient  would 
grow  exceedingly  tired  and  even  disgusted  if  milk  alone  was  given, 
hence  a  mixed  fluid  diet  such  as  is  used  in  the  Presbyterian  Hospital, 
New  York  City.  6 

•  F.  P.  Kinnicut,  "Diets  Used  in  the  Presbyterian  Hospital,"  New  York  City. 


TYPHOID  FEVER  265 

PRESBYTERIAN  HOSPITAL  DIET   LIST 

8  A.M.  Milk  and  coffee,  each  120  c.c.  (4  oz.). 

10  A.M.  Milk,  hot  or  cold,  240  c.c.  (8  oz.). 

12  M.  Oatmeal  gruel,  120  c.c.  (4  oz.),  with  milk  60  c.c.  (2  oz.). 

2  r.M.  Junket  with  cane  and  milk  sugar. 

4  P.M.  Oatmeal  gruel,  120  c.c.  (4  oz.),  with  milk  60  c.c.  (2  oz.). 

6  P.M.  Junket  with  cane  and  milk  sugar. 

8  P.M.  Hot  milk,  240  c.c.  (8  oz.). 

10  P.M.  Whey,  180  c.c.  with  1  whole  egg  and  sherry. 

12  P.M.  Oatmeal  gruel,  120  c.c.  (4  oz.)  with  milk. 

2  A.M.  Junket  with  60  c.c.  (2  oz.)  cane  and  milk  sugar. 

4  a.m.  Milk,  240  c.c.  (8  oz.). 

6  A.M.  Milk,  240  c.c.  (8  oz.). 

15  gm.  (i  oz.)  of  lactose  added  to  each  of  the  four  milk  feedings. 

The  following  foods  and  diet  lists  are  used  with  success  in  various 
hospitals : 

From  1  to  1 J  quarts  of  milk  and  1  pint  of  cream  and  lactose, 
beginning  with  1  tablespoonful  in  each  milk  feeding  and  raising 
the  amount  day  by  day  until  the  patient  is  taking  2  oz.  (4  table- 
spoonfuls)  at  each  milk  feeding,  given  in  eight  feedings.  This 
may  be  given  as  milk,  hot  or  cold,  or  it  may  be  made  into  cocoa, 
soup,  ice  cream,  junket,  or  on  the  cereal. 

LIQUID   DIET 

Milk  Broths  (chicken,  beef,  mutton. 
Cream  or  clam),  reenforced  with  lac- 
Buttermilk  tose  or  egg  or  given  plain 
Whey  Proprietary  infant  foods 
Koumiss  Cream  soups,  beef  juice,  liquid 
Zoolak  peptonoids,  panopepton 
Fermillac  Orangeade 
Albumenized  fruit  juices,  egg.    Lemonade 

and  orange  juice  Eggnog 

Milk  shake  Milk  punch 


266 


DIETETICS  FOR  NURSES 


Malted  milk 
Malted  milk  shake 
Albumenized  milk 
Strained  gruels  (except  oats) 


Cream,  egg  and  vichy 
Chocolate  malted  milk 
Milk  gruels 


SOFT   OR  SEMI-SOUD   DIETS 

Eggs  —  creamed,  soft-cooked,  poached,  custards,  baked  custard. 

Toast  —  milk  or  cream  toast. 

Gelatine  —  meat,  fruit,  or  wine  jellies. 

Junkets  —  plain,  egg,  or  cocoa. 

Cereals  —  fine,  strained  cereals,  except  oats. 

Rice  —  boiled  or  in  custard. 

Tapioca  —  custard. 

Baked  or  mashed  potato. 

Cornstarch  or  arrowroot  pudding. 

Ice  cream. 

Meat  is  not  given  until  convalescence  is  established,  and  then  in 
only  the  most  digestible  form,  such  as  rare  beefsteak  or  lamb  chop 
or  a  small  piece  of  broiled  breast  of  chicken. 

DIET  LIST  USED  IN  HIGH  CALORIE  DIETS    FOR  TYPHOID 

FEVER 


Time 

Material 

Amount 

Calories 

6    A.M. 

Hot  milk 

4  oz. 

78 

Cream 

2  oz. 

76 

Lactose 

^  oz.  (15  gm.) 

60 

8    A.M. 

Milk 
Water 

3  oz. 
3oz. 

59 

Cocoa 

Cocoa 
Cream 

2  tsp. 
1  oz. 

35 

38 

Sugar 

2  tsp. 

40 

Lactose 

^  oz.  (1  tbs.) 

60 

Egg 

1 

60 

Toast 

1  slice 

(well  moistened) 

73 

Butter 

h  oz. 

73 

10    A.M. 

Buttermilk 

6  oz. 

56 

TYPHOID   FEVER 
DTE^  LIST  —  Continued 


267 


Time 

Material 

Amount 

Calories 

12    M. 

Cream  of  pea  soup 

6oz. 

300 

Mashed  potato 

20  gm. 

28 

Toast 

1  slice 

73 

Butter 

20  gm. 

84 

Coffee  and  milk 

3  oz,  each 

59 

Cream 

2oz. 

76 

Sugar 

2  tsp. 

40 

Lactose 

20  gm. 

80 

3  P.M. 

^           .  .          J     Orange  juice 
Orange  juice  and  J  E^e 

3oz. 

1 

38 
60 

®^^                      [  Lactose 

30  gm. 

120 

5  P.M. 

Farina 

3oz. 

102 

Milk 

2oz. 

59 

Cream 

2oz. 

76 

Lactose 

20  gm. 

80 

Egg 

1 

60 

Apple  sauce 

1  oz. 

30 

Cream 

1  oz. 

38 

Cocoa 

6oz. 

108 

or 

Tea  and 

3oz. 

0 

Milk 

3oz. 

78 

Sugar 

2  tsp. 

40 

Toast 

1  slice 

73 

7  P.M. 

Gruel 

4  oz. 

102 

Cream 

2oz. 

76 

Lactose 

15  gm.  (^  oz.) 

60 

9  P.M. 

Broth 

6oz. 

18 

Egg  white 

1 

13 

12  m. 

Milk 

4  oz. 

78 

Cream 

2  oz. 

76 

Lactose 

20  gm. 

80 

3    A.M. 

Milk  or 

4  oz. 

78 

Malted  milk 

1  tbs. 

58 

Cream 

2oz. 

76 

Lactose 

20  gm. 

Total  calorie 

80 
3  3145 

Advantages  of  Newer  Treatment.  —  A  marked  difference  is 
noticed  in  the  patients  treated  by  the  old  starvation  diets  and  those 
given  the  high  calorie  diet.     Dr.  Coleman  states  ^  that  while  the 

7  "Journal  of  American  Medical  Association,"  Aug.  4,  1917. 


268  DIETETICS  FOR  NURSES 

range  of  temperature  is  apparently  unaffected,  the  total  duration 
of  the  disease  is  shortened*  in  some  instances  by  months  through 
the  shortening  of  convalescence.  He  further  states  that  certain 
s^inptoms  which  have  hitherto  been  attributed  to  the  specific 
action  of  the  typhoid  bacillus  have  been  discovered  to  be  due  to 
faulty  methods  of  treatment,  particularly  to  an  inadequate  or 
improperly  balanced  diet.  The  various  investigators  who  have 
made  the  study  and  treatment  of  this  disease  a  lifework  claim 
that  the  mortality  from  this  disease  has  been  tremendously  reduced 
by  the  use  of  the  high  calorie  diets  which  maintain  the  nutrition 
of  the  patient  throughout  the  disease,  thus  eliminating  the  horrors 
of  the  long,  tedious  convalescence  which  tried  the  nerves  and 
patience  of  the  patient,  the  nurse,  and  the  physician.  There  is  no 
doubt  that  so  far  as  the  administering  of  this  diet  is  concerned  it 
requires  more  effort  on  the  part  of  the  nurse  than  the  old  treatment 
of  a  glass  of  milk  every  two  or  three  hours.  It  is  necessary  for  the 
nurse  to  be  able  to  carry  out  the  orders  as  expressed  in  the  diet 
lists,  to  be  able  to  compute  the  proteins  (nitrogen),  fats,  and  car- 
bohydrates in  a  food  or  recipe.  But  this  is  readily  done  by 
studying  the  tables  given  in  the  first  section  of  this  text.  She 
must  likewise  be  able  to  recognize  the  symptoms  as  they  arise. 
In  hospitals,  the  urinalysis  is  made  as  a  routine  procedure.  In 
private  cases  the  physician  will  either  have  the  analyses  made  or 
expect  the  nurse  to  be  able  to  make  the  simple  tests  .^ 

One  of  the  greatest  difficulties  attending  the  administering  of  the 
high  calorie  diet  is  persuading  the  patient  to  take  sufficient  food 
for  his  needs.  The  fluids  are  often  more  difficult  to  give  in  quantity 
than  the  more  solid  foods,  and  it  requires  much  tact  on  the  part  of 
the  nurse  to  prevent  a  refusal  of  the  necessary  fluids.  However,  if 
the  patient  is  possessed  of  even  ordinary  intelligence,  an  explanation 
of  the  reasons  for  the  large  amount  of  food  will  as  a  rule  be  all  that 
is  necessary.  Few  individuals  will  willingly  prolong  an  illness 
attended  w^ith  the  discomforts  generally  present  in  typhoid  fever. 

Hemorrhage  occurs  in  a  certain  percentage  of  cases  of  typhoid 
regardless  of  the  diet,  whether  it  be  a  strictly  milk  diet  or  the  high 

8  See  urinalysis,  p.  299. 


TYPHOID  FEVER  269 

calorie  diet  just  described.  The  measures  to  combat  them  are 
essentially  the  same.  It  is  necessary  to  guard  against  excessive 
tympanites  since  the  pressure  therefrom  against  the  ulcerated 
intestinal  walls  may  cause  perforation  resulting  in  hemorrhage. 
Lactose  at  times  causes  an  evolution  of  gas  as  do  fats  under  cer- 
tain circumstances.  Hence  it  is  necessary  to  follow  symptoms  and 
watch  the  stools  in  order  to  determine  which  food  material  is  to 
blame  for  the  tympanites  and  reduce  the  allowance  of  that  food 
in  the  diet. 

Idios5mcrasies  against  Milk.  —  Certain  individuals  manifest 
an  inability  to  take  milk.  This  may  be  real  or  imaginary.  When 
it  is  a  true  idiosyncrasy,  it  may  be  found  necessary  to  substitute 
some  other  food  for  the  milk  in  the  diet,  but  great  care  should  be 
taken  to  determine  the  real  character  of  the  disagreement  before 
eliminating  so  invaluable  a  food  from  the  diet.  When  the  dis- 
agreement proves  merely  a  distaste  for  milk,  some  of  the  different 
methods  used  in  disguising  it,  such  as  flavoring  or  coloring,  may 
be  practiced.  Otherwise,  it  is  well  under  the  circumstances  to 
use  some  of  the  pre-digestive  methods  in  order  to  increase  its 
utilization.  It  is  well  to  emphasize  the  value  of  accurate  data 
on  this  subject,  as  it  is  exceedingly  difficult  to  administer  a  high 
calorie  diet  without  milk  in  some  form. 

Essential  Points.  —  Thus  the  dietary  in  typhoid  fever  is  seen 
to  be  the  most  important  part  of  the  treatment.  A  careful  study 
of  the  tables  will  enable  the  nurse  to  do  her  part  in  nourishing  the 
patient.  It  is  necessary  that  she  be  able  to  compute  the  nitrogen, 
carbohydrates,  and  fats  in  a  diet  and  arrange  these  constituents 
in  such  a  way  as  to  give  the  desired  amount  of  each  in  the*  dietary 
and  in  a  form  acceptable  to  the  patient. 

f 

SUMMARY 

Rate  of  Metabolism  is  greatly  increased  in  typhoid  fever  even 
over  other  febrile  conditions,  not  only  on  account  of  the  eleva- 
tion and  duration  of  the  fever,  but  also  on  account  of  the  activi- 
ties of  the  specific  bacteria  in  the  intestinal  tract  which  differen- 
tiate this  disease  from  other  febrile  conditions. 


270  DIETETICS  FOR  NURSES 

Energy  Expenditures  and  Requirements  of  the  body  in  ty- 
phoid fever,  on  account  of  the  character  of  the  disease,  are  much 
greater  than  those  of  the  normal  individual  and  must  be  met  by 
an  increase  in  the  diet  if  the  body  is  to  be  saved  from  destruction. 

The  Bowels.  —  Diarrhea  develops  during  any  period  of  the 
disease  due  to  excess  amount  of  fat  or  to  a  disagreement  of  some 
of  the  other  food  constituents.  It  is  advisable  to  cut  down  the 
allowance  of  cream  temporarily  and  to  watch  stools  and  other 
symptoms  for  evidences  of  dietetic  errors. 

Hemorrhage  must  be  guarded  against  by  eliminating,  as  far 
as  possible,  all  substances  liable  to  cause  an  excessive  gas  forma- 
tion in  the  intestines. 

Absorption  of  Food  is  as  a  rule  good.  The  patient  is  usually 
able  to  handle  a  large  quantity  of  food  provided  it  is  judiciously 
administered  with  a  due  regard  to  the  symptoms  manifested  at 
the  time. 

Simplicity  of  Diet  is  absolutely  essential.  All  the  materials 
must  be  selected  carefully  according  to  the  physician's  orders  and 
prepared  with  the  greatest  care  in  order  to  prevent  digestive  dis- 
turbances. 

High  Calorie  Diet  is  one  in  which  the  fuel  value  of  the  food 
ingested  meets  or  exceeds  the  energy  expenditures  of  the  patient. 
Foods  composing  the  diet  are,  milk  and  eggs  for  the  proteins,  with 
carbohydrates  and  fats  in  their  simplest  and  most  digestible  form 
to  balance  the  diet. 

Administering  a  High  Calorie  Diet  is  accomplished  successfully 
provided  the  nurse  exercises  care  with  regard  to  the  symptoms 
arising  !rom  time  to  time.  These  must  be  carefully  noted  and 
reported  to  the  physician,  for  in  this  way  only  is  it  possible  to  give 
a  sufficient  quantity  of  food  to  cover  the  excessive  breaking  down 
of  the  body  due  to  the  disease. 

Fluid  Diet  is  at  times  necessary  since  certain  patients  cannot 
tolerate  a  high  calorie  diet,  but  this  is  a  point  decided  by  the 
physician.  A  fluid  diet  consists  of  fluids  alone,  milk  in  particular, 
with  broths  and  fruit  beverages  as  ordered.  The  milk  is  given 
in  definite  amounts  and  at  stated  intervals. 


TYPHOID  FEVER  271 

Milk  Diet  is  one  consisting  solely  of  milk  or  in  which  the  bulk 
of  the  nourishment  is  furnished  by  milk.  It  may  be  reenforced 
or  not  as  desired.  Lactose  is  the  substance  commonly  used  as  a 
reenforcing  agent.  It  is  impossible  to  cover  the  energy  expendi- 
tures of  typhoid  fever  with  a  milk  diet  even  if  it  is  perfectly  ad- 
ministered, but  certain  complications  make  it,  at  times,  the  only 
rational  method  of  feeding. 

The  Advantages  of  High  Calorie  Diet  over  other  diets  are 
distinctly  noticeable  in  typhoid  fever  patients.  Those  treated 
by  this  method  are  more  comfortable  during  the  course  of  the 
disease  and  are  saved  a  long,  tedious  convalescence  which  has 
made  the  starvation  treatment  a  thing  of  horror  in  the  past.  The 
return  to  health  is  attended  by  a  much  better  physical  condition 
when  the  patients  are  well  nourished  than  is  possible  when  they 
are  kept  on  practically  a  starvation  ration.  The  mortality  from 
the  disease  has  been  materially  lessened  by  the  administration  of 
the  high  calorie  diet. 

Acidosis  may  develop  in  typhoid  fever  patients  and  must  be 
guarded  against.  The  behavior  of  the  fat  in  the  body  should  be 
carefully  watched  and  the  amount  reduced  at  the  first  evidence  of 
acidosis.  At  the  same  time  an  increase  in  the  carbohydrates  may 
assist  in  overcoming  the  condition.  This  adjusting  of  the  diet, 
however,  is  entirely  in  the  hands  of  the  physician. 

The  Kidneys  in  typhoid  fever  patients  are  under  a  great  strain, 
chiefly  on  account  of  the  increased  rate  of  metabolism.  Great 
care  must  be  exercised  in  the  dietetic  treatment  to  prevent  these 
organs  from  being  overworked  with  a  consequent  development  of 
nephritic  conditions. 

Care  of  the  Mouth  in  any  febrile  condition  is  important,  but  es- 
pecially so  in  typhoid  fever,  where  the  disease  itself  causes  a  most 
unpleasant  taste  in  the  mouth.  This  prevents  the  taking  of 
nourishment  with  any  degree  of  comfort,  hence  the  mouth  should 
be  cleansed  before  and  after  each  feeding.  Any  of  the  aseptic 
mouth  washes  may  be  used. 

Thirst  may  be  relieved  by  plain  or  carbonated  waters,  fruit 
beverages,  and  crushed  ice.     When  in  certain  complications  the 


272  DIETETICS  FOR  NURSES 

fluids  in  the  diet  are  in  a  measure  restricted,  ice  is  used  and  water 
is  given  in  spoonful  doses.  This,  however,  is  the  exceptional, 
rather  than  the  ordinary  state  of  affairs. 

Increasing  the  Diet  after  a  fluid  diet  must  be  made  with  great 
care  in  order  to  prevent  a  relapse.  Following  the  high  calorie 
diet  the  increase  is  simple.  The  patient  passes  from  the  prescribed 
foods  to  meat  with  apparently  no  effort.  The  increase  should  not 
be  made,  however,  until  convalescence  is  firmly  established. 

Reenforcing  the  Diet.  —  On  account  of  the  great  increase  in 
the  rate  of  metabolism  and  because  of  the  difiiculty  of  furnishing 
the  requisite  number  of  calories  in  the  diet,  reenforcing  agents 
such  as  lactose,  eggs,  some  forms  of  casein,  or  beef  preparations 
are  used. 

Idios5mcrasies  against  certain  foods  are,  at  times,  manifested 
by  patients.  Efforts  must  be  made  to  determine  whether  they 
are  real  or  imaginary  before  eliminating  any  food  which  may  be  of 
importance  to  their  future  welfare. 


CHAPTER  XVI 
FEVERS  IN.  GENERAL 

Fever  is  an  abnormal  condition  characterized  by  an  elevation 
of  body  temperature,  quickened  respiration  and  circulation,  and 
a  certain  amount  of  tissue  waste.  This  elevation  of  temperature 
may  be  due  to  various  conditions,  such  as  local  inflammation, 
infectious  diseases,  disturbed  metabolism  and  food  poisoning 
(ptomaine) . 

Tissue  Waste  in  Fevers.  —  Fevers  of  short  duration,  such  as 
accompany  colds,  tonsillitis,  chicken  pox  and  intermittent  fever, 
remittent  fever,  and  at  times  malarial  fever,  do  not  cause  sufficient 
tissue  waste  to  make  the  nutrition  the  important  feature  of  the 
treatment.  In  ptomaine  poisoning  the  tissue  waste  may  be  great, 
but  it  is  the  result  of  the  poisoning,  as  is  the  fever,  so  that  the  diet 
needs  to  be  adjusted  only  after  the  disturbance  has  abated.  In 
the  beginning,  starvation  is  instituted  and  the  fever  disappears 
when  the  poisoning  is  controlled. 

Treatment  of  Fevers  of  Short  Duration.  —  In  all  fevers  of  short 
duration  then,  the  treatment  is  directed  with  the  following  points 
in  mind :  (1)  relieving  the  cause,  (2)  preventing  gastro-intestinal 
disturbances,  (3)  saving  the  heart,  kidneys,  etc.,  extra  strain. 

Dietetic  Treatment.  —  In  doing  this  the  diet  is  so  formulated 
as  to  meet  the  above-mentioned  conditions,  and  fluids  seem,  the 
best  form  in  which  food  can  be  given  to  bring  about  the  desired 
results.  The  quantity  of  fluids  should  be  small  and  the  intervals 
between  feedings  short.  Two-hour  intervals  seem  best  in  the 
beginning.  These  intervals  are  lengthened  as  the  fever  decreases 
and  the  amount  of  food  at  each  feeding  increased.  When  con- 
valescence is  established,  semi-solid,  soft  or  convalescent  diet 
may  replace  the  fluids  and  the  patient  gradually  brought  back  to 
a  normal  diet. 

T  273 


274  DIETETICS  FOR  NURSES 

Fluid  Diet.  —  The  following  foods  constitute  a  fluid  diet :  milk, 
whole  milk,  plain,  peptonized,  or  albumenized,  buttermilk,  koumiss, 
malted  milk,  milk  shake,  milk  punch,  cream,  whey ;  fruit  beverages, 
plain,  albumenized,  or  mixed  with  whole  raw  egg ;  eggnog,  milk  and 
ginger  ale,  cocoa,  strained  gruels,  broths  reenforced  with  egg  or 
plain.     Carbonated  water  may  be  added  to  milk  or  fruit  beverages. 

Schedule  of  Feeding.  —  The  following  schedule  may  be  used 
as  a  guide  in  fevers  of  short  duration :  ^ 

I 

6  oz.  hot  milk  or  cocoa. 

6  oz.  broth  reenforced  with  egg. 

Milk  shake. 

Oatmeal  gruel,  4  oz. ;  2  oz.  cream. 

Albumenized  orange  juice,  4  oz. ;  1  egg  white. 

6  oz.  broth  reenforced  with  egg  white. 

6  oz.  cocoa. 

6  oz.  malted  milk. 

4  oz.  hot  milk  and  2  oz.  cream. 

The  above  furnishes  approximately  750  calories. 

II 

6  oz.  cocoa. 

4  oz.  oatmeal  gruel,  2  oz.  cream. 

Eggnog. 

Milk  broth  reenforced  with  egg.     (3  oz.  milk,  3  oz.  broth, 

1  egg  white.) 
Cream,  egg  and  vichy. 
Albumenized  milk,  6  oz. 
Hot  malted  milk  chocolate,  6  oz.  ♦ 

Milk  broth  reenforced  with  egg. 
4  oz.  oatmeal  gruel,  2  oz.  cream. 
6  oz.  malted  milk  (half  water,  half  milk). 

Furnishing  approximately  1500  calories. 

^  In  scarlet  fever  and  other  conditions  in  which  the  kidneys  may  be  involved  the 
above  diet  is  not  given  unless  advised  by  physician  in  charge . 


7 

A.M. 

9 

A.M. 

11 

A.M. 

1 

P.M. 

3 

P.M. 

5 

P.M. 

7 

P.M. 

9 

P.M. 

M. 

and 

7 

A.M. 

7 

A.M. 

9 

A.M. 

11 

A.M. 

1 

P.M. 

3 

P.M. 

5 

P.M. 

7 

P.M. 

9 

P.M. 

12 

M. 

4 

A.M. 

FEVERS   IN  GENERAL  275 

III 

7  A.M.  Oatmeal  gruel,  4  oz.,  2  oz.  cream. 

9  A.M.  Orange  eggnog. 

11  A.M.  Malted  milk  chocolate  (3  oz.  milk,  3  oz.  water). 
1  P.M.  Clam  broth  (milk),  6  oz. 

3  P.M.  Milk  shake,  4  oz. ;  2  oz.  cream. 

5  P.M.  Cornmeal  gruel,  4  oz. ;  2  oz.  cream. 

7  P.M.  Hot  cocoa,  6  oz. 

9  P.M.  Hot  malted  milk. 

12  M.  Hot  milk,  4  oz.,  2  oz.  cream. 

4  A.M.  Hot  milk,  4  oz. ;  2  oz.  cream. 

Furnishing  approximately  1460  calories. 

The  two  night  feedings  may  be  omitted  if  patient  is  asleep. 

These  diets  will  be  seen  to  be  below  the  maintenance  require- 
ments in  health,  but  the  need  for  care  in  preventing  gastro-intestinal 
disturbances  makes  it  safer  to  have  it  so  for  a  few  days,  especially 
if  the  elevation  of  temperature  is  great.  After  the  temperature 
becomes  normal  the  following  foods  may  be  added  to  the  diet : 

Soft  or  Convalescent  Diet.  —  Cream  soups,  soft-cooked,  creamed, 
or  poached  egg,  soft  or  baked  custard,  junkets,  egg,  cocoa,  or  plain 
vanilla  ice  cream,  soft  toast,  milk  or  cream,  buttered  toast,  cereals, 
gelatine  jellies,  fruit,  wine,  or  meat  jellies,  vegetable  purees,  baked 
white  potato,  apple  sauce,  baked  apple,  fruit  whip,  blanc-mange, 
broiled  lamb  chops,  beefsteak,  or  chicken,  sweetbreads,  broiled 
or  creamed  brains. 

Sample  Menus.  —  The  following  menu  is  a  sample  convales- 
cent dietary : 

•  Breakfast 

7 :  30  A.M.     Cream  of  wheat  3  oz.,  cream  1  oz. 
1  soft-cooked  or  poached  egg. 

1  slice  of  toast  buttered. 

6  oz.  cocoa  or  milk  flavored  with  coffee. 

2  tablespoonfuls  of.  strained  prune  pulp  with  2  oz. 
cream. 

10 :  30  A.M.     Albumenized  orange  juice. 


276  DIETETICS  FOR  NURSES 

Dinner 

12  :  30  P.M.     Cream  of  pea  soup,  6  oz. 

1  baked  potato  with  butter. 
1  slice  of  buttered  toast. 

1  cup  of  cocoa  or  1  glass  of  milk  or  buttermilk. 
3  :  30  P.M.     Ginger  ale  and  milk,  3  oz.  each. 

Supper 

6  p.m.      2  slices  of  buttered  toast  moistened  with  4  oz.  milk 
and  2  oz.  cream. 

1  soft-cooked  egg  or  3  tablespoonfuls  of  well-cooked 
cereal  or  2  tablespoonfuls  of  boiled  rice. 

2  tablespoonfuls  of  apple  sauce  served  with  1  table- 
spoonful  of  cream. 

1  cup  of  cocoa,  malted  milk,  whole  milk,  or  butter- 
milk. 
9  p.m.      4  oz.  hot  milk,  2  oz.  cream,  or  1  cup  of  cocoa  or  malted 
milk. 

The  return  to  normal  diet  is  made  with  caution  tliat  the  digestion 
of  the  patient  may  not  be  upset  or  the  temperature  raised  again 
by  overfeeding.. 

Energy  Requirements.  —  In  fevers  of  short  duration  it  is  not 
difficult  to  regulate  the  amount  of  food  necessary  for  the  mainte- 
nance of  the  patient,  since  the  body  will,  as  a  rule,  adjust  itself 
when  the  cause  of  the  fever  has  heen  removed.  At  times,  however, 
it  is  necessary  to  make  an  effort  to  tempt  the  appetite  of  the 
patient  when  convalescence  is  established,  that  recovery  may  be 
made  more  rapid  and  complete. 

Care  of  the  Mouth.  —  Probably  there  is  nothing  more  essential 
in  the  treatment  of  fevers  in  general  and  typhoid  fever  in  particular 
than  the  care  of  the  mouth.  Well-nourished  patients  rarely  ever 
show  the  dry,  cracked  tongue  and  lips  that  was  formerly  one  of 
the  common  occurrences  in  typhoid  fever.  However,  in  any  febrile 
condition  the  mouth  is  "apt  to  acquire  a  disagreeable  taste ;   this 


FEVERS  IN  GENERAL  277 

"  bad  taste  "  is  so  prominent  in  certain  cases  as  to  render  it  difficult 
for  the  patient  to  eat.  This  can  be,  to  a  great  extent,  eUminated 
by  the  use  of  aseptic  mouth  washes.  When  the  patient  is  not 
strong  enough  to  rinse  the  mouth  before  and  after  eating,  the 
nurse  must  use  a  swab  for  the  purpose.  The  food  must  be  care- 
fully selected  and  attractively  served  and  every  effort  made  to 
make  food  as  dainty  and  palatable  as  possible. 

Thirst.  —  Thirst  is  relieved  with  crushed  ice,  fruit  beverages, 
and  carbonated  waters.  In  certain  conditions  it  is  necessary  to 
limit  the  fluids,  but  in  typhoid  fever  the  giving  of  the  requisite 
amount  of  liquids  is  one  of  the  most  difficult  tasks  confronting 
the  nurse.  It  is  wise  to  find  out  the  beverages  particularly  liked 
by  the  patient  and,  whenever  it  is  possible,  make  use  of  them.  As 
a  rule  alcohol  is  not  necessary  in  the  diet  of  typhoid  fever  patients. 
However,  in  certain  cases  of  that  disease,  as  well  as  in  febrile  con- 
ditions induced  by  other  causes,  the  use  of  alcoholic  stimulation 
may  be  necessary ;  it  must  be  left  to  the  discretion  of  the  physician 
to  prescribe  it. 

SUMMARY 

Intestinal  Disturbances  are  accountable  for  the  majority  of 
the  fevers  of  short  duration  during  infancy  and  childhood,  and  in 
many  of  those  cases  in  adults. 

Malaria  causes  an  elevation  of  temperature  which  is,  as  a 
rule,  of  short  duration. 

Contagious  Diseases,  such  as  scarlet  fever,  measles,  whoop- 
ing cough,  and  mumps,  are  likewise  accompanied  by  a  more  or 
less  elevation  of  temperature. 

Treatment  consists  of  a  period  of  rest  in  bed,  with  an 
abstinence  from  food,  in  order  that  the  disease  may  manifest 
itself,  and  also  that  any  offending  food  material  which  may 
cause  the  fever  may  have  an  opportunity  to  pass  out  of  the 
body. 

The  Heart,  in  some  of  the  diseases  accompanied  by  an 
elevation  of  temperature,  is  more  or  less  strained  ;  this  is  particu- 
larly true  in  tonsillitis,  diphtheria,  etc. 


278  DIETETICS  FOR  NURSES 

The  Kidneys  are  likewise  taxed  in  certain  diseases,  even 
when  the  fever  is  not  great  or  lasting ;  this  is  found  to  be  the  case 
in  scarlet  fever,  tonsillitis,  etc. 

Dietetic  Treatment  consists  in  giving  no  food  for  a  period 
lasting  from  twenty-four  to  forty-eight  hours.  This  is  followed 
by  a  liquid  diet,  milk  and  broth  particularly,  which  is  continued 
as  long  as  the  fever  remains. 

Convalescent  Diet  is  instituted  as  soon  as  the  fever  has  dis- 
appeared and  acute  symptoms  subside. 

Thirst  is  apt  to  be  great  with  any  elevation  of  temperature.  It 
is  relieved  by  water,  crushed  ice,  and  fruit  beverages. 

The  Mouth  requires  much  care,  even  in  fevers  of  short  duration. 
A  simple  antiseptic  wash  should  be  used  several  times  each  day. 

Nitrogen  Equilibrium  is  not  sufficiently  disturbed  in  such 
cases  to  require  taking  into  account.  Should  the  disease,  however, 
develop  into  one  causing  a  material  breaking  down  of  the  body 
tissues,  measures  must  be  instituted  to  prevent  the  upsetting  of  the 
nitrogen  balance  in  the  body. 


CHAPTER  XVII 
DISEASES  OF  THE  RESPIRATORY  TRACT 

TUBERCULOSIS,   PNEUMONIA,   AND  TONSILLITIS 
TUBERCULOSIS 

The  dietetic  treatment  for  tuberculosis  must,  as  in  any  other 
pathological  condition,  depend  largely  upon  the  general  condition 
of  the  patient,  and  the  symptoms  manifested  at  the  time. 

Character  of  Disease.  —  The  disease  may  have  reached  an  acute 
stage  in  which  the  rise  of  temperature  is  marked  and  the  progress 
of  the  tubercular  symptoms  rapid,  or  it  may  be  found  to  be  an 
old  chronic  condition  in  which  the  progress  is  slow. 

Again,  the  patient  may  be  found  to  be  suffering  from  a  tuber- 
culosis which  is  neither  acute  nor  very  slow.  Each  of  these 
stages  requires  slightly  different  treatment  which,  however,  for 
the  main  part  is  much  the  same. 

Individuals  having  an  incipient  form  of  tuberculosis  have 
been  known  to  develop  an  acute  form  of  the  disease  upon  being 
subjected  to  a  strenuous  treatment  for  some  other  and  entirely 
different  condition.  This  has  been  especially  noticeable  in  certain 
individuals  to  whom  the  starvation  treatment  is  given. 

Dietetic  Treatment  in  Acute  Stage.  —  The  dietetic  treatment  of 
the  acute  tuberculosis  under  such  circumstances  must  necessarily 
be  adapted  to  that  of  the  original  disease  for  which  starvation  was 
believed  to  be  necessary.  The  forbidden  foods  must  still  be 
omitted  from  the  dietary,  but  in  these  cases  it  is  found  advisable 
not  to  prolong  the  starvation  treatment  but  to  substitute  foods^ 
which  will  do  the  least  harm  under  the  circumstances.  This  is 
necessary  to  cover  the  energy  requirements  of  the  body  and  to 
make  good  the  tissue  wasted  through  the  development  of  the 
specific  disease. 

279 


280  DIETETICS  FOR  NURSES 

Dietetic  Treatment  in  Chronic  Stage,  —  The  diet  for  tuberculosis 
has  been  so  widely  discussed  and  so  universally  used  that  a  few 
words  only  seem  necessary  here.  One  of  the  chief  points  to  be  em- 
phasized is  the  danger  arising  from  gastro-intestinal  disturbances. 
The  digestive  apparatus  of  the  tubercular  individual  is  more  apt 
to  be  impaired,  so  that  any  undue  exertion  required  to  digest  a 
meal  is  likely  to  bring  about  disturbances  more  or  less  serious  in 
character. 

Method  of  Administering  Diet.  —  For  this  reason  it  is  no  longer 
the  custom  to  stuff  the  patient  in  an  effort  to  overcome  the  in- 
evitable tissue  waste,  since  such  treatment  in  many  cases  defeats 
the  end  for  which  it  was  intended,  bringing  on  acute  indigestion, 
or  at  times  diarrhea,  which  might  readily  cause  a  greater  loss  of 
body  weight  than  could  possibly  be  produced  by  the  surplus  food 
given. 

Adjusting  the  Diet.  —  More  and  more  is  it  coming  to  be  under- 
stood that  the  diet  must  be  adjusted  to  suit  the  individual.  Three 
wholesome  meals  a  day  are  insisted  upon,  with  lunches  given  be- 
tween the  morning  and  midday  meal  and  during  the  course  of  the 
afternoon.  Many  patients  are  found  to  sleep  better  after  they 
have  partaken  of  a  light  lunch,  consisting  of  hot  milk,  malted  milk, 
or  like  beverages  and  crackers,  so  that  this  third  meal  is  added 
to  the  other  five.  In  this  way  the  individual  suffering  with 
tuberculosis  is  assured  of  an  efficient  diet  to  meet  the  needs  of 
the  body  without  overburdening  the  digestive  apparatus  or  over- 
taxing the  excretory  organs.  The  increased  metabolism  taking 
place  in. such  patients,  due  both  to  the  specific  bacteria  and  to  the 
febrile  condition,  is,  as  far  as  possible,  provided  for. 

Schedule  of  Diets.  —  The  following  dietary  regime  may  be 
useful  in  formulating  menus  for  tubercular  patients : 

Breakfast 
Fruits. 
5  oz.  cereals  with  cream. 

1  or  2  eggs,  simply  prepared  to  prevent  indigestion. 

2  slices  of  bacon,  ham ;  fish  cake  or  chop. 


DISEASES  OF  THE   RESPIRATORY  TRACT      281 

2  slices  of  toast  or  crusty  rolls  with  butter. 
Coffee,  tea,  or  cocoa,  with  or  without  cream.^ 

Lunch 

Vegetable  or  cream  soups. 

Cold  meat,  lamb  chops,  oysters,  or  fish. 

Baked  white  or  sweet  potato. 

1  green  vegetable,  —  greens,  cabbage,  spinach,  or  string  beans. 

Stewed  fruit  or  baked  apple. 

Rice  or  tapioca  pudding. 

Tea. 

Bread  and  butter. 

At  the  end  of  the  meal  one  glass  containing  two-thirds  milk  and 
one-third  cream.  If  the  latter  disturbs  the  digestion  reduce  the 
amount  temporarily,  or  add  one-half  the  contents  of  a  tube  of 
peptonizing  powder,  or  one-quarter  of  a  glass  of  limewater. 

Dinner 

Meat,  lamb,  mutton,  chicken,  duck,  game,  or  fish. 
Mashed  or  creamed  potatoes. 

I  or  2  green  vegetables.  , 
Simple  salads. 

Simple  desserts  consisting  of  puddings,  custards,  wine  or  fruit 
jellies,  ices  or  ice  cream,  sponge  cake  or  angel  food  cake. 

The  milk  and  cream  is  taken  at  the  end  of  the  meal  as  directed 
above. 

Lunches 

II  A.M.,  4  P.M.,  9  P.M.,  consisting  of  milk,  malted  milk,  jun- 
ket, buttermilk,  albumenized  broth,  albumenized  fruit  juices, 
cream,  egg,  and  vichy,  eggnogs,  served  with  crackers  or  sponge 
cake ;  cereal  gruels  and  raw  eggs  taken  with  water,  milk,  or  sherry  , 
may  likewise  form  a  part  of  this  diet,  since  the  nourishment  in 
them  is  both  concentrated  and  palatable. 

^  The  addition  of  cream  to  coffee  produces  acute  indigestion  in  certain  individuals, 
hence  the  nurse  must  be  governed  by  this  point  in  formulating  the  diet. 


282  DIETETICS  FOR  N^URSES 

Use  of  Eggs.  —  The  old  method  of  forcing  the  patient  to  eat  a 
dozen  or  more  raw  eggs  a  day  is  no  longer  used,  but  three  or  four 
a  day  will  be  of  undoubted  value  to  the  patient,  provided  they 
agree.  There  are  patients,  however,  with  whom  eggs  act  almost 
as  a  poison,  and  in  these  cases  it  is  decidedly  unwise  to  force  them. 

Use  of  Milk.  —  Milk  is  to  be  used  abundantly.  If  it  should 
disagree,  it  may  be  peptonized  or  modified  with  limewater.  At 
any  rate,  every  effort  should  be  made  to  enable  the  patient  to 
drink  at  least  one  quart  a  day,  and  more,  if  possible. 

If  it  fails  to  agree  even  when  so  treated,  it  should  be  abandoned, 
since  the  discomfort  caused  under  the  circumstances  is  more 
detrimental  to  the  welfare  of  the  individual  than  any  benefit 
which  he  may  gain  by  the  small  amount  which  may  be  absorbed. 

High  Calorie  Diet.  —  As  long  as  the  patient  is  in  bed  the  diet 
cannot  be  as  full  as  it  is  made  when  he  is  up  and  about,  as  the 
body  is  then  using  more  material  to  provide  for  the  extra  exertion 
and  needs  more  food  to  replace  that  which  has  been  utilized.  Con- 
sequently the  high  calorie  diet  ^  will  be  found  as  a  rule  sufficient. 
As  soon  as  the  patient  is  able  to  receive  more  food  without  incurring 
digestional  disturbances,  it  should  be  supplied,  keeping  ever  in 
mind  the  danger  of  its  upsetting  his  digestion. 

Advice  to  Patients.  —  The  patient  must  be  impressed  with  the 
necessity  for  living  a  simple,  wholesome  life,  free  from  excesses  of 
all  kinds.  The  need  for  a  regular  regime  in  the  beginning  must 
be  strongly  emphasized.  Too  strenuous  exercise  and  the  conse- 
quent over-fatigue  at  times  completely  overcome  all  the  good  which 
has  been  accomplished  in  weeks  or  even  months  of  studied  effort, 
so  that  rest  is  an  essential  part  of  the  tubercular  regime.  The 
patient  should  sleep  from  eight  to  ten  hours  out  of  every  twenty- 
four,  and  if  this  sleep  is  taken  in  the  open,  that  is,  in  a  tent  or  on  a 
sleeping  porch,  the  benefits  derived  therefrom  are  inestimable. 

The  Bowels.  —  The  bowels  should  move  every  day,  even  if 
some  gentle  laxative  or  an  enema  has  to  be  used  to  bring  about  the 
desired  result.  In  a  majority  of  cases,  mineral  oil  or  bran  muffins, 
prunes,  raisins,  and  figs  prepared  with  senna  will  be  entirely  suffi- 

2  See  "High  Calorie  Diet  for  Typhoid  Fever,"  Chapter  XV. 


DISEASES   OF  THE  RESPIRATORY  TRACT      283 

cient,  however,  and  these  substances  are  much  less  harmful  than 
drugs,  for  the  habit  of  taking  purgatives  becomes  a  fixed  one  in  a 
short  time,  and  is  especially  liable  to  become  so  when  the  patient 
is  forced,  by  reason  of  the  sedentary  life,  to  depend  on  some  such 
measures. 

Massage.  —  Massage  has  been  found  beneficial  in  many  cases, 
giving  the  needed  exercise  to  the  body,  which  it  is  otherwise  unable 
to  obtain. 

CHKONIC  TUBERCULOSIS 

In  chronic  tuberculosis,  the  patient  should  be  instructed  in  the 
care  necessary  for  his  protection.  He  should  be  advised  to  report 
to  the  physician  any  symptoms  occurring  during  the  course  of 
the  disease,  especially  any  hemorrhage.  He  must  be  reassured  of 
the  chances  of  recovery,  even  after  hemorrhage  has  occurred. 
It  is  not  well  to  encourage  the  habit  of  taking  the  temperature 
or  weighing  daily,  since  the  knowledge  of  the  fluctuations  which 
inevitably  occur  in  these  conditions  may  worry  the  patient  to 
such  an  extent  as  to  interfere  with  his  final  recovery. 

Rest,  Sleep,  and  Fresh  Air.  —  Moderation  in  physical  exertion, 
wholesome  food  at  regular  intervals,  plenty  of  rest  and  sleep, 
preferably  in  the  open,  and  an  effort  made  to  look  forward  to  a 
complete  recovery  will  go  far  toward  bringing  about  the  desired 
result.  The  tubercular  patient  who  sets  his  mind  on  recovery, 
refusing  to  be  discouraged  by  the  numerous  setbacks  which  may 
from  time  to  time  occur,  has  a  much  greater  chance  of  living  a 
long  and  useful  life  than  the  patient  who  makes  no  effort  in  this 
direction. 

Reenforcing  the  Diet.  —  The  following  reenforced  foods  have 
been  found  valuable  in  the  diet  for  tuberculosis,  especially  in  those 
cases  which  are  confined  to  bed  and  in  which  the  effort  to  eat  causes 
more  or  less  gastric  distress : 

Milk,  whole  milk,  milk  and  cream,  milk  diluted  with  Apollinaris 
water,  peptonized,  modified  milk,  reenforced  with  egg  or  egg  w^hite 
or  reenforced  with  one  to  four  tablespoonfuls"  of  lactose,  malted 
milk,  buttermilk,  cream,  egg,  and  vichy,  milk  shake,  milk  punch, 


284  DIETETICS  FOR  NURSES 

malted  milk  shake,  chocolate  or  cocoa  malted  milk,  albumenized 
fruit  juices,  egg  and  orange,  egg  and  wine,  reenforced,  if  desired, 
with  lactose,  albumenized  broths,  proprietary  infant  foods,  such 
as  Eskay's  Food,  Nestle's  Food,  Mellin's  Food,  Racahout,  cream 
soups  reenforced  with  lactose  or  egg,  junkets,  and  ice  cream. 

Pneumonia 

The  diet  in  pneumonia  is  of  considerable  importance,  since  in 
this  condition  the  strength  of  the  patient  is  taxed  by  reason  of 
the  character  of  the  disease,  and  the  only  means  of  attaining 
endurance  to  carry  him  through  this  trying  period  is  by  providing 
proper  nourishment. 

Dietetic  Treatment.  —  The  same  general  outline  of  diet  is  used 
as  in  acute  infectious  fevers,  milk  forming  the  basis  of  the  diet. 
The  patient  is  given  an  abundance  of  water  and  other  beverages  in 
addition  to  the  other  fluid  foods  to  relieve  the  thirst  which  is  so 
often  a  common  symptom  in  this  disease. 

It  is  sometimes  found  advisable,  however,  on  account  of  the 
vomiting  which  may  occur,  to  give  a  more  concentrated  form  of 
nourishment,  in  which  case  liquid  peptonoids,  trophonine,  and 
panopepton  furnish  a  form  of  nourishment  which  is  both  strength- 
ening and  stimulating  in  character,  and  for  these  reasons  particu- 
larly desirable.  Freidenwald  and  Ruhrah  advise  against  the  use 
of  starches  and  sugars  in  most  cases  of  pneumonia. 

Daily  Diet  Schedule.  —  The  same  fluid  diets  used  in  acute 
fevers  and  administered  at  two-hour  intervals  are  advisable  here. 
The  following  regime  is  used  in  pneumonia : 

6  A.M.  6  oz.  malted  milk. 

8  A.M.  6  oz.  cocoa. 

10  A.M.  4  oz.  oatmeal  or  cornmeal  gruel  with  2  oz.  cream. 
12  M.      6  oz.  chicken  broth  reenforced  with  1  egg  white. 

2  P.M.  6  oz.  malted  milk  chocolate. 

4  P.M.  6  oz.  albumenized  orange  juice. 

6  P.M.  6  oz.  chicken  or  beef  broth,  reenforced  with  egg  white. 

8  P.M.  6  oz.  hot  milk. 


DISEASES  OF  THE  RESPIRATORY  TRACT      285 

Night  feeding  consisting  of  milk,  malted  milk,  or  reenforced 
broth  may  be  given  at  12  and  4  a.m.  if  patient  is  awake. 

The  above  diet  may  be  varied  by  adding  some  of  the  beverages 
mentioned  in  the  diet  for  tuberculosis  or  fevers. 

Convalescent  Diet  Schedule.  —  As  the  acute  symptoms  subside 
and  convalescence  advances,  the  following  diet  may  be  instituted : 

I 

Breakfast    3  to  4  oz.  cereal  gruel  with  2  oz.  cream. 

1  soft-cooked  egg. 
10 :  30  A.M.  6  oz.  chicken  broth,  reenforced  with  egg,  or  6  oz. 
albumenized  orange  or  grape  juice. 
1  P.M.  6  oz.  oyster  soup  with  rolled  crackers. 
J  cup  wine  jelly  with  1  tbs.  cream. 
1  glass  (6  oz.)  milk  —  2  parts  milk,  1  part  cream. 
3  P.M.  Milk  shake  (4  oz.  milk,  1  egg  white). 
Supper  4  oz.  farina  with  1  oz.  cream. 

6  oz.  cocoa. 
9  P.M.  6  oz.  malted  milk. 
Hot  milk,  broth,  or  malted  milk  may  be  given  during  the  night 
at  12  or  4  a.m.  if  patient  is  awake. 

II 

Breakfast  4  oz.  orange  juice  on  cracked  ice. 

3  or  4  oz.  strained  oatmeal  with  cream  or  butter. 

1  slice  soft  toast. 
6  oz.  cocoa. 

10  A.M.  1  soft-cooked  egg  on  toast. 

6  oz.  milk. 
Dinner  6  oz.  cream  of  celery  soup. 

2  oz.  rice. 

4  oz.  custard  (soft  or  baked). 
6  oz.  milk  or  cocoa. 

3  P.M.  5  oz.  cream,  egg,  and  vichy. 
Supper  1  soft-cooked  egg. 

1  small  baked  potato. 

6  oz.  cocoa  or  malted  milk. 


286  DIETETICS  FOR  NURSES 

III 

Breakfast  Stewed  prunes. 

3  or  4  oz.  cream  of  wheat  with  1  oz.  cream. 
1  soft-cooked  egg. 

1  slice  of  toast  with  butter. 
6  oz.  cocoa  or  milk. 

10 :  30  a.m.  Eggnog  (1  egg,  4  oz.  milk,  2  oz.  cream,  1  tbs.  whisky  or 
sherry  wine). 
Dinner  Cream  of  spinach  soup. 

2  oz.  mashed  potatoes. 

2  oz.  green  peas.  » 

1  slice  toast  with  butter. 

2  oz.  rice  or  tapioca  custard. 
3  P.M.  6  oz.  albumenized  fruit  juice. 

Supper  1  slice  toast. 

1  poached  egg. 

6  oz.  cocoa  or  hot  milk. 

2  or  3  oz.  stewed  fruit  or  prune  whip. 

The  diet  may  be  reenforced  with  lactose  and  meat  added  only 
when  convalescence  is  well  established. 

Tubercular  Nursing.  —  The  nurse  must  keep  in  mind  that  the 
lungs  are  in  a  condition  more  or  less  out  of  commission,  and  their 
work  of  excretion  is  forced  upon  the  kidneys.  For  this  reason,  as 
well  as  on  account  of  the  increased  strain  upon  the  heart,  it  is  neces- 
sary to  keep  the  diet  light  and  avoid  all  foods  which  may  in  any  way 
exert  an  unfavorable  influence  upon  either  the  kidneys  or  the  heart. 

Milk  Diet.  —  A  strict  milk  diet  has  been  found  necessary  in 
certain  cases  of  pneumonia,  but  this  is  used  only  while  the  febrile 
condition  lasts,  after  which  the  diet  is  gradually  increased,  as  in 
the  case  of  acute  nephritis  and  in  diseases  of  the  heart,  to  meet 
the  needs  of  the  individual. 

TONSILLITIS 

Dietetic  Treatment.  —  The  diet  in  this  condition  is  much  the 
same  as  that  used  in  other  acute  febrile  conditions,  that  is,  a  fluid 
diet,  the  basis  of  which  is,  as  a  rule,  milk. 


DISEASES  OF  THE  RESPIRATORY  TRACT       287 

The  development  of  nephritis  and  certain  cardiac  symptoms 
at  times  follow  attacks  of  tonsillitis,  and  for  this  reason  the  urine 
must  be  examined  frequently  and  the  diet  carefully  adjusted 
to  avert,  if  possible,  this  danger.  When  acute  nephritis  does 
follow  the  attack  of  tonsillitis,  the  diet  must  necessarily  be 
adjusted  to  meet  that  condition  rather  than  that  of  the  original 
disease. 

Special  Diets.  —  The  Mosenthal  diet,  and  at  times  the  Karell 
Cure,  is  used  with  more  or  less  success.  This,  however,  is  adjusted 
by  the  physician.  It  remains  for  the  nurse  to  report  any  un- 
favorable symptoms  as  soon  as  they  occur,  and  to  carry  out  the 
line  of  dietetic  treatment  deemed  advisable  by  the  physician. 


SUMMARY 
TUBERCULOSIS 

Form.  —  Acute  and  chronic  in  character.  The  chief  aim  of  the 
treatment  in  the  former  is  to  prevent  its  development  into  a 
chronic  form. 

Rest.  —  Sleep,  preferably  in  the  open  air,  in  a  tent  or  on  a 
sleeping  porch. 

Proper  Surroundings  should  be  striven  for.  The  patient 
should  be  kept  tranquil  in  mind  and  body,  free  from  disturbing 
worries  and  assured  of  the  possibility  of  recovery  with  proper 
care. 

Diet  should  be  adequate  without  being  too  abundant;  stuff- 
ing the  patient  is  no  longer  considered  necessary,  in  fact  it  is 
believed  that  forcing  the  eating  of  large  quantities  of  eggs,  etc., 
defeats  its  own  ends,  upsetting  the  digestion  and  causing  a  disgust 
for  food  almost  impossible  to  overcome. 

Gastro-intestinal  Disturbances  are  apt  to  develop  as  the  disease 
progresses.  These  are  treated  as  in  other  conditions  so  compli- 
cated, except  that  the  period  of  starvation  must  necessarily  be 
limited  on  account  of  the  metabolic  waste  already  taking  place 
from  the  disease  itself. 


288  DIETETICS  FOR  NURSES 

PNEUMONIA 

The  Lungs,  as  in  pulmonary  tuberculosis,  are  the  seat  of  in- 
fection and  are  temporarily  hampered  in  their  work  of  excretion. 

The  Kidneys  bear  the  brunt  of  the  extra  work  caused  by  the 
impaument  of  the  lungs,  consequently  all  unnecessary  work  must 
be  spared  these  organs  if  they  are  to  be  prevented  from  being  over- 
taxed. 

Nephritis  is  one  of  the  complications  apt  to  develop  when  the 
kidneys  are  not  sufficiently  strong  to  carry  on  their  own  work  and 
that  generally  done  by  the  lungs. 

The  Heart.  —  Cardiac  symptoms  are  also  likely  to  develop 
during  attacks  of  pneumonia  and  make  the  disease  one  to  be 
dreaded  and  guarded  against. 

The  Diet.  —  The  dietetic  treatment  in  pneumonia  is  like  that 
used  in  acute  infectious  diseases,  fevers  in  general,  fluids '  con- 
stituting the  form  of  diet  and  milk  the  chief  food,  as  long  as  there 
is  an  elevation  of  temperature. 

TONSILLITIS 

The  Heart.  —  As  in  pneumonia,  the  development  of  cardiac 
symptoms  must  be  guarded  against.  These  symptoms  may  not 
develop  at  once  but  show  later  during  or  after  convalescence. 

The  Kidneys.  —  Nephritis  also  develops  in  some  patients  and 
the  treatment  is  directed  as  far  as  possible  to  prevent  its  develop- 
ing into  a  chronic  form. 

Dietetic  Treatment  is  the  same  as  used  in  acute  infectious 
conditions,  fevers  of  short  duration,  taking  care  to  institute  the 
diet  for  acute  nephritis  should  the  patient  show  evidences  of  this 
disease. 


CHAPTER   XVIII 

DIETETIC  TREATMENT  BEFORE  AND  AFTER 
OPERATION 

PREOPERATIVE  FEEDING 

The  dietetic  treatment  which  is  essential  before  and  after 
operations  is  deserving  of  attention  here,  since  it  constitutes  one 
of  the  points  so  frequently  overlooked  or  slighted.  As  a  rule  the 
treatment  depends  (1)  upon  the  character  of  the  disease  for  which 
surgical  intervention  is  necessary,  and  (2)  upon  the  general  health 
and  physical  condition  of  the  patient  in  question. 

Preparatory  Treatment.  —  In  many  cases  it  is  found  to  be  advis- 
able to  build  up  the  patient  before  subjecting  her  to  the  shock  of 
an  operation,  and  the  more  serious  the  operation  the  more  neces- 
sary this  "  building-up  "  process. 

The  character  of  the  disease  also  has  much  to  do  with  the  pre- 
liminary diet.  In  certain  pathological  conditions  involving  the 
gastro-intestinal  tract,  for  example,  the  patient  comes  to  the 
surgeon  after  medical  treatment  has  failed  to  give  relief  and 
surgical  intervention  is  necessary  to  save  life.  The  body  is  found 
to  be  in  a  condition  bordering  on  starvation,  anemic  and  exhausted 
from  insufficient  nourishment.  The  functions  of  the  blood-making 
organs  have  become  out  of  gear,  as  it  were,  and  the  blood  conse- 
quently is  deficient  in  one  or  more  of  its  essential  elements.  For 
such  patients  it  is  wise  to  attempt  to  reenforce  and  strengthen 
their  bodies  before  operation,  that  they  may  have  more  endurance 
to  withstand  the  shock  which  is  more  or  less  unavoidable. 

Adjusting  the  Diet.  —  In  any  case  where  preliminary  diet  is 
prescribed  the  condition  for  which  the  operation  is  necessary  deter- 
mines the  nature  of  the  diet ;  for  example,  if  the  operation  is  to  be 
upon  the  kidney,  the  diet  beforehand  would  naturally  be  in  the 
nature  of  a  nephritic  one  to  save  the  diseased  organ  unnecessary 
u  289 


290  DIETETICS  FOR  NURSES 

work.  If  the  stomach  or  intestinal  tract  required  surgical  care, 
the  diet  would  necessarily  be  formulated  to  meet  the  particular 
needs  of  the  organ  in  question,  an  analysis  of  the  stomach  content 
furnishing  the  keynote  of  the  diet.  In  any  case  the  food  must 
be  simple  in  character  and  well  prepared.  All  food  in  any  way 
liable  to  bring  about  indigestion  should  be  studiously  avoided. 

Habits.  —  The  habits  of  the  patient  must  be  regulated  so  that 
she  may  not  "  overdo  '' ;  at  the  same  time,  gentle  exercise  may 
be  the  very  thing  needed  to  give  an  impetus  to  the  appetite  and 
thus  assist  in  the  adding  of  strength  for  the  approaching  ordeal. 
Many  patients  respond  readily  to  a  change  of  air  and  scene  and 
frequent  small  meals  instead  of  a  few  large  ones,  —  a  lunch  in  the 
mid-morning  and  mid-afternoon  hours,  consisting  of  a  glass  of 
milk  and  a  cracker  or  malted  milk  chocolate  or  reenforced  fruit 
juices.  A  cup  of  warm  milk  before  retiring  induces  the  much- 
needed  sleep,  hence  is  advisable  under  the  circumstances. 

The  Bowels.  —  The  bowels  must  be  kept  open.  Coarse  bread 
such  as  that  made  from  bran  or  graham  flour  is  advisable.  Prunes 
and  figs  cooked  with  senna  leaves  are  likewise  simple  laxatives 
which  are  both  palatable  and  effective.  For  stubborn  cases  of 
constipation  it  is  often  found  that  a  teaspoonful  of  a  conserve 
made  with  a  third  of  a  pound  each  of  raisins,  prunes,  and  figs 
ground  fine,  with  an  ounce  of  senna  leaves  added,  taken  at  bed- 
time and  before  breakfast,  will  overcome  the  condition  and  make 
the  patient  more  comfortable  and  the  general  health  better. 

Preliminary  Light  Diet.  —  The  day  before  the  operation  the 
diet  must  be  light ;  the  intestinal  tract  must  not  be  filled  with  a 
food  mass  which  is  difficult  to  get  rid  of.  On  the  morning  of  the 
operation  the  patient  is  given  no  food  if  the  operation  is  to  be  per- 
formed at  an  early  hour,  otherwise  a  cup  of  tea,  coffee,  weak  cocoa, 
or  broth  with  a  cracker  is  given.  Some  physicians  give  a  glass  of 
milk  at  this  time,  while  others  do  not.  It  is  the  physician  who  must 
decide  the  question  if  there  is  any  doubt  about  it.  The  stomach 
must  be  empty  before  administering  the  anesthetic. 

In  certain  emergency  operations  when  it  has  been  impossible  to 
prepare  the  patient  ahead,  the  diflBculties  attending  the  adminis- 


POSTOPERATIVE  FEEDING  291 

tering  of  the  ether  are  sometimes  greatly  increased.  The  cleansing 
of  the  stomach  and  intestinal  tract  oftentimes  eliminates  or 
materially  decreases  the  nausea  and  vomiting  which  so  often  forms 
one  of  the  most  dreaded  sequences  of  the  operation.  For  this 
reason  many  surgeons  require  the  patient  to  be  given  lavage  before 
leaving  the  operating  room. 

Total  Abstinence.  —  No  food  is  given  for  twenty-four  hours 
following  the  operation  (1)  on  account  of  the  nausea  and  vomiting 
which  so  often  follows  the  giving  of  an  anesthetic  —  ether  partic- 
ularly —  and  (2)  because  the  entire  organism  is  better  for  a  com- 
plete rest. 

Routine  Treatment.  —  The  routine  treatment  in  uncomplicated 
cases  is  rest,  then  water,  very  hot  or  iced,  or  carbonated,  or  vichy 
in  spoonful  doses,  then  albumen  water,  broth,  etc.,  then  milk, 
buttermilk,  koumiss,  etc.,  after  which  the  semi-solids,  etc.,  until 
a  normal  diet  is  reached.  After  a  week  or  more  the  character 
of  the  operation  certainly  determines  the  dietetic  treatment. 
To  quote  Dr.  Thomas  S.  Brown,^  "  To  give  the  same  diet  after 
pyloroplasty,  gastro-enterostomy,  gall-bladder  operation,  or  gastric 
resection  as  we  would  after  operations  for  fracture  of  the  thigh  or 
cancer  of  the  breast  shows  a  basic  ignorance  of  the  pathologic 
physiology  of  the  former  group  of  cases."  "We  should  remember 
that  hyperacidity  remains  long  after  the  underlying  cause  has  been 
removed  and  it  is  tempting  providence,  to  say  the  least,  to  ply 
these  patients  with  tomato  soup,  salad  dressing,  and  coarse  food 
in  the  early  stages  of  their  convalescence." 

Character  of  Diet.  —  It  must  be  kept  in  mind  that  the  character 
of  the  diet  is  of  vital  importance,  especially  in  the  after-treatment 
of  operations  upon  the  stomach.  In  gastro-enterostomy,  for 
example,  the  food  mass  passes  from  the  stomach  directly  into  the 
upper  part  of  the  small  intestine  through  the  new  opening.  Thus 
the  semi-liquid  food  highly  acid  in  character  comes  in  direct  con- 
tact with  the  delicate  intestinal  walls  which  are  accustomed, 
not  to  the  acid,  but  to  a  neutral  or  alkaline  medium. 

1  "Some  Gastro-intestinal  Notes,"  "The  Medical  Clinics  of  North  America," 
Vol.  1,  No.  1,  pp.  192-193,  by  Thomas  R.  Brown,  Johns  Hopkins  Hospital. 


292  DIETETICS.  FOR  NURSES 

Adjusting  Diet  to  Disease.  —  Thus  it  is  demonstrated  that  unless 
care  is  used  in  selecting  the  diet  this  portion  of  the  intestinal  tract 
will  be  injured ;  hence  the  nurse  must  understand  which  foods  are 
liable  to  stimulate  an  excess  flow  of  acid  in  the  stomach  and  avoid 
them.  She  must  also  keep  in  mind  that  the  foods  given  must  be 
in  a  semi-liquid  or  very  finely  divided  condition,  since  the  mechan- 
ical efforts  made  by  the  musculature  of  the  gastric  organ  act  as  a 
direct  stimulant  to  the  secretory  cells  of  that  organ. 

Much  of  the  responsibility  thus  rests  upon  the  nurse  whose 
business  it  is  to  administer  the  diet.  The  efforts  of  the  best  sur- 
geon in  the  world  may  be  entirely  overcome  by  a  careless,  thought- 
less, or  ignorant  nurse. 

Rectal  Feeding.  —  In  some  cases  it  is  found  necessary  to  nourish 
the  patient  more  than  is  possible  by  mouth.  This  is  especially  so 
with  emaciated  and  very  weak  patients  and  for  those  who  have 
undergone  operations  upon  the  mouth  or  throat  and  in  some  of 
the  above-mentioned  stomach  cases  when  the  passage  of  any  food 
over  the  newly-operated-upon  surfaces  is  inadvisable.  In  these 
cases  rectal  feeding  is  resorted  to  and  from  two  to  three  nutrient 
enemas  ^  alternated  with  saline  enemas  are  given  daily. 

Under  ordinary  conditions  when  the  patient  has  not  been 
operated  upon  for  gastro-intestinal  disorders,  gall-bladder  or 
kidney  diseases,  the  dietetic  regime  is  as  follows : 

Postoperative  Feeding.  —  First  day:  starvation,  a  little  hot 
or  cold  water  or  carbonated  water  may  be  given  if  there  is  no 
nausea  or  vomiting.  If  nausea  or  vomiting  persists,  a  few  spoon- 
fuls of  champagne  or  clam  broth  or  juice  will  often  check  or  relieve 
it  entirely.  Fluids  alone  must  be  given  during  the  first  forty-eight 
hours  after  the  operation.  When  stimulation  is  necessary,  albumen 
water  or  coffee  containing  a  spoonful  of  brandy  ^  will  be  found  use- 
ful. When  nausea  entirely  disappears,  well-skimmed  broth,  milk, 
clam  or  oyster  broth,  buttermilk,  koumiss,  malted  milk,  may  be 
given.    A  gradual  return  to  the  normal  diet  is  made,  adding  soft 

»  See  Formulas  for  Nutrient  Enemata,  p.  143. 
8  See  Albumen  Water  with  Brandy,  p.  221. 


POSTOPERATIVE  FEEDING  293 

toast,  soft-cooked  eggs,  junket,  ice  cream,  meat,  wine,  or  fruit 
jellies  before  solid  food  is  introduced  into  the  dietary. 

After-care  in  Feeding.  —  Care  must  be  observed  to  prevent 
indigestion  after  almost  any  operation,  but  especially  after 
abdominal  operations  there  is  a  great  tendency  to  form  gas,  hence 
anything  which  in  any  way  increases  the  tendency  may  bring 
about  a  condition  of  extreme  discomfort  and  even  acute  pain  to  the 
patient.  For  this  reason  it  is  unwise  to  follow  too  closely  the  de- 
sires of  the  patient  as  to  the  food  to  be  eaten ;  for  example,  corned 
beef  and  cabbage  may  be  the  thing  of  all  others  desired  by  the 
patient,  but  it  would  be  the  height  of  folly  to  risk  such  a  meal  until 
all  danger  of  digestional  disturbances  were  at  an  end.  It  is  wiser 
to  avoid  such  disturbances  than  to  trust  to  relieving  them  after 
they  occur.  The  digestion  of  even  a  perfectly  normal  individual 
is  at  a  disadvantage  when  that  individual  is  deprived  of  outdoor 
exercise.  How  much  more  so  will  it  be  when  the  entire  organism  is 
so  taxed  by  the  ordeal  through  which  it  has  just  passed.  Con- 
valescence is  never  hastened  by  imprudent  eating,  and  a  condition 
as  bad  as  the  original  may  be  brought  on  by  lack  of  care  on  the 
part  of  the  one  whose  business  it  is  to  feed  the  patient. 

CONDITIONS  REQUIRING  SPECIAL  DIETS 

Diet  After  Appendicitis.  —  After  a  simple  operation  for  appendi- 
citis the  same  regime  is  carried  out  as  in  stomach  and  intestinal 
operations :  fluids  on  the  second  day,  soft  diet  on  the  third, 
and  solid  food  of  the  simplest  character  and  prepared  in  the 
simplest  way  may  be  given  on  the  fifth  and  sixth  days.  When, 
however,  the  operation  has  been  of  a  more  serious  character,  for 
example,  when  there  was  pus  formation  or  a  gangrenous  appendix, 
the  feeding  by  mouth  must  not  be  instituted  for  five  days  or  more, 
nutrient  enemas  being  used  instead.  Patients  have  been  known 
to  die  from  exhaustion  after  operations  upon  the  stomach  and 
intestines,  not  on  account  of  the  operation  but  on  account  of  the 
lack  of  reserve  power  and  endurance  to  carry  them  through  the 
ordeal  without  a  sustaining  diet  to  overcome  it.     Under  the 


294  DIETETICS  FOR  NURSES 

circumstances  Dr.  F.  Ehrlich  ^  advises  the  following  routine 
method  :  "So  soon  as  the  nausea  from  the  anesthetic  has  worn  off 
the  patient  gets  tea,  red  wine,  and  gruel ;  on  the  day  after  the 
operation  he  is  given  sweetbreads  in  bouillon  even  if  it  nauseates 
him ;  if  the  nausea  is  persistent,  his  stomach  is  washed.  On  the 
second  day  finely  chopped  cooked  squab,  chicken,  or  veal,  is  added ; 
on  the  third  day,  beef,  potato  puree  and  cakes ;  on  the  fourth, 
chopped  (raw)  ham,  soft  zwieback,  and  soft-boiled  eggs.  On  the 
fifth,  white  bread  and  spinach.  After  the  seventh  day  the  meat  is 
not  chopped,  and  the  patient  returns  gradually  to  normal  diet. 
The  bowels  are  regulated  by  oil  enemas." 

Diet  After  Operation  upon  Gall  Bladder  or  Liver.  —  The  dietetic 
treatment  in  these  cases  is  like  that  of  any  other  abdominal 
operation  except  for  the  character  of  the  food.  Fats  are  not  well 
handled  by  the  body  of  such  individuals  and  should  be  eliminated 
as  far  as  possible  from  the  diet.  Broths  must  be  skimmed  carefully 
to  remove  fat  and  milk  when  given  should  be  skimmed  or  given 
in  the  form  of  buttermilk  or  koumiss. 

Diet  After  Operations  upon  the  Kidneys.  —  The  diet  admin- 
istered after  operations  upon  these  organs  is  logically  one  in 
which  those  foods  which  are  entirely  dependent  upon  the  kidneys 
for  their  elimination  are  restricted.  In  a  former  chapter  the  fate 
of  the  foods  in  metabolism  was  explained ;  the  protein  foods  were 
seen  to  be  the  ones  leaving  the  body  chiefly  by  way  of  the  kidneys 
and  for  this  reason  in  the  diet  after  operations  upon  these  organs, 
as  well  as  in  that  administered  in  disturbances  affecting  their  func- 
tioning powers,  this  food  constituent,  the  protein  of  meat  in 
particular,  must  necessarily  be  restricted.  The  upsetting  of  the 
nitrogen  equilibrium  is  for  so  short  a  period  after  kidney  operations 
that  this  feature  need  not  be  considered  here.  The  diet  under 
the  circumstances  is  essentially  the  same  as  that  given  during 
acute  attacks  of  nephritis. 

<"Diet  in  Health  and  Disease,"  p.  555,  by  Freidenwald  and  Ruhrah. 


POSTOPERATIVE  FEEDING  295 

SUMMARY 

Factors  Affecting  Diet  before  and  after  operations  must  be 
considered  under  two  heads,  namely,  the  character  of  the  disease 
for  which  the  operation  is  considered  necessary  and  the  general 
physical  condition  of  the  patient  at  the  time. 

Emaciation  and  Anemia  are  often  encountered  in  patients 
having  certain  gastrb-intestinal  disturbances  for  which  surgical 
intervention  was  found  to  be  necessary.  At  times  a  preliminary 
up-building  treatment  is  required  before  it  is  considered  wise  to 
submit  the  patient  to  the  shock  of  so  serious  an  operation. 

Adjusting  the  Diet  according  to  the  character  of  the  disease 
for  which  the  operation  is  to  be  performed  is  most  important.  It 
is  not  always  possible  to  build  up  the  body  beforehand,  but  in 
many  cases  it  is  necessary  to  make  the  effort.  At  times  the  reen- 
forcing  of  the  diet  and  a  certain  amount  of  gentle  massage  will 
enable  the  patient  to  pass  through  the  trying  ordeal  more  comfort- 
ably than  would  otherwise  be  possible. 

Selecting  the  Diet  to  conform  to  the  character  of  the  disease 
is  as  important  a  factor  in  the  recovery  of  the  patient  as  food  itself. 
This  selection  is  left  largely  to  the  nurse,  consequently  it  is  neces- 
sary that  she  should  understand  just  which  foods  are  indicated 
or  contraindicated  under  the  circumstances,  and  adjust  the  diet 
after  the  abstinence  period  accordingly.  For  example,  the  diet 
fulfilling  all  the  needs  of  a  patient  who  has  just  undergone  an 
operation  for  a  broken  leg  might  be  highly  injurious  for  a  patient 
just  operated  upon  for  some  disturbance  of  the  liver  or  kidneys. 
The  diet  given  after  must  be  essentially  like  that  given  just  before 
the  operation,  in  order  that  the  affected  organ  may  have  an  oppor- 
tunity to  heal  and  return  to  its  normal  functioning  power. 

Gastro-intestinal  Disturbances  must  be  avoided,  both  before  and 
after  the  operation.  In  the  preliminary  treatment,  when  every 
effort  is  being  made  to  increase  the  strength  and  endurance  of  the 
patient,  such  disturbances  do  away  with  any  gain  brought  about 
by  judicious  dieting.  After  the  operation,  attacks  of  indigestion 
not  only  cause  pain  and  discomfort  as  a  result  of  the  gas  formation. 


296  DIETETICS  FOR  NURSES 

but  may  cause  symptoms  far-reaching  and  even  dangerous  in 
their  effects.  The  diet,  then,  must  be  composed  of  the  simplest 
food  and  prepared  in  the  most  careful  manner,  the  amount  of  food 
given  at  a  time  must  be  small  —  it  is  wiser  to  feed  the  patient 
oftener  than  to  run  the  risk  of  indigestion  by  giving  more  than 
can  be  readily  handled  by  the  already  taxed  digestive  apparatus. 

The  Bowels  must  be  kept  open  in  the  majority  of  cases.  Peri- 
stalsis is  stimulated  by  the  giving  of  water  and  fruit  beverages 
as  soon  as  it  is  advisable  to  give  anything  by  mouth. 

Reenforcing  the  Diet  is  at  times  necessary  in  order  that  the 
patient's  strength  may  be  kept  up.  In  such  cases  lactose,  eggs 
and  some  of  the  predigested  casein  or  beef  preparations  are  found 
to  be  valuable. 

Before  the  Operation  the  patient  must  be  made  ready  to  take 
the  anesthetic.  This  is  done  by  preventing  an  accumulation  of 
food  in  the  intestinal  tract.  The  day  before  the  operation,  then, 
it  is  necessary  to  limit  the  diet  materially  by  giving  food  in  small 
amounts.  The  light  diets  prescribed  in  acute  conditions  are  as  a 
rule  suitable,  unless  otherwise  indicated. 

The  Day  of  the  Operation  a  cup  of  tea,  coffee,  or  broth  may 
usually  be  given,  with  a  cracker,  unless  the  operation  is  to  be  per- 
formed early  in  the  morning,  in  which  case  the  patient  is  given  no 
food  at  all.  Some  physicians  allow  a  glass  of  milk  on  the  day  of 
the  operation,  but  this  is  left  entirely  to  the  physician  in  charge. 

After  Operation  a  period  of  total  abstinence  from  both  food  and 
water  is  necessary  in  order  not  to  increase  or  induce  nausea  and 
vomiting.  As  soon  as  these  symptoms  subside,  unless  otherwise 
indicated,  a  certain  amount  of  hot,  cold,  or  carbonated  water 
may  be  given.  After  this,  albumen  water  may  form  the  first 
nutrient  administered.  Milk,  broth  and  fruit  beverages  follow 
the  giving  of  albumen  water,  after  which  the  semi-solids,  such  as 
soft  eggs,  gelatine  and  milk  soups,  institute  the  convalescent 
diet. 

The  Character  of  the  Diet  after  the  operation  depends  wholly 
upon  the  nature  of  the  disease  for  which  the  operation  was  deemed 
necessary. 


POSTOPERATIVE  FEEDING  297 

Diet  After  Gastro-enterostomy  must  be  adjusted  in  order  not 
to  increase  the  acid  content  of  the  gastric  organ,  otherwise  the 
delicate  mucous  linings  of  the  intestines  would  be  subjected  to 
direct  contact  with  materials  which  are  irritating  in  character, 
owing  to  the  fact  that  the  mass  passes  through  the  new  opening 
and  has  thus  been  deprived  of  the  neutralizing  agents  found  in 
the  upper  part  of  the  intestinal  tract.  Under  the  circumstances 
milk,  albumen  water  and  fine  cereal  gruels  are  the  best  foods  from 
which  to  formulate  the  diet  after  the  necessary  period  of  abstinence 
and  fluid  diet. 

After  Appendicitis,  as  a  rule,  no  food  is  given  for  five  days  in 
cases  where  there  has  been  a  pus  formation  and  the  appendix 
gangrenous.  Otherwise  the  routine  treatment  diet  is  given  — 
water,  then  albumen  water,  followed  by  broth,  milk  and  fruit 
beverages,  fine  cereal  gruels,  etc. 

After  Liver  and  Gall-bladder  Operations  the  character  of 
the  food  must  be  considered.  The  fats  are  not  well  handled  in 
such  conditions  and  must  be  avoided  as  far  as  possible.  Broths 
must  be  well  skimmed  and  the  milk  fat  free.  Buttermilk  and 
koumiss  are  probably  the  most  suitable  forms  in  which  to  give 
milk  in  these  cases. 

After  Kidney  Operations  the  work  of  elimination  must  be 
limited  as  far  as  possible  in  such  cases.  While  it  is  impossible 
to  rest  the  organ  entirely,  the  giving  of  a  proper  diet  under  the 
circumstances  will  do  much  toward  relieving  the  strain  placed  upon 
it.  The  protein  foods,  with  the  exception  of  milk,  must  be  excluded 
from  the  diet.  The  regime  practiced  in  acute  nephritis  gives  the 
most  satisfactory  results. 


CHAPTER  XIX 

URINALYSIS 

The  importance  of  the  kidney  functions  has  been  clearly  demon- 
strated. Urine,  which  is  the  fluid  secreted  by  these  organs,  is  one 
of  the  most  important  sources  of  information,  not  only  as  to  the 
manner  in  which  the  body  utilizes  food  in  health,  but  as  an  index 
to  certain  pathological  conditions,  the  processes  of  which  are  more 
or  less  indicated  by  the  products  excreted  in  the  urine. 

Function  of  the  Kidneys.  —  The  kidneys,  as  has  already  been 
stated,  furnish  a  means  by  which  the  greater  part  of  the  waste 
products  of  the  body  are  eliminated  and  in  addition  to  this  func- 
tion they  adjust  the  salts  in  the  body.  In  an  early  chapter  the 
function  of  the  salts  in  food  was  explained.  A  certain  amount  of 
these  substances,  we  know,  is  absolutely  necessary  to  carry  on  the 
work  in  the  body,  but  harm  comes  when  a  surplus  is  retained  in 
excess  of  that  which  can  be  used  in  performing  the  various  processes. 
Consequently  the  function  of  the  kidneys  to  adjust  the  salts  balance 
is  by  no  means  their  least  important  one. 

Elimination  of  the  Toxins.  —  The  toxic  substances  manufac- 
tured in  the  body  and  those  resulting  from  bacterial  action  upon 
unabsorbed  proteins  are  likewise  eliminated  in  the  urine.  Thus 
it  can  be  readily  understood  how  necessary  it  is  to  keep  these 
organs  in  good  repair,  that  they  may  continue  their  work  in  an 
efficient  manner. 

It  is  necessary  from  a  pathological  standpoint  for  the  nurse  to 
understand  the  making  of  some  of  the  simpler  tests,  that  she  may 
simplify  her  own  work  and  that  of  the  physician. 

Excretion  of  Carbon  Dioxide  and  Water.  —  We  have  already 
spoken  of  the  combinations  of  carbon  and  hydrogen  compounds. 
These  substances  being  oxidized,  the  carbon  dioxide  produced  is 

298 


URINALYSIS  299 

eliminated  by  way  of  the  lungs  and  the  water  is  excreted  partly 
by  way  of  the  lungs  and  skin,  but  chiefly  by  way  of  the  kidneys. 

Oxidation  and  Excretion  of  Nitrogenous  Substances.  —  When 
the  nitrogenous  substances  are  oxidized,  the  used-up  oxygen 
products  are  eliminated  by  the  kidneys  in  the  form  of  urea  and 
more  or  less  highly  oxidized  substances,  such  as  ammonia  and  other 
salts,  purin  bases,  and  creatinine. 

Uric  Acid,  the  chief  of  the  oxidation  products  of  nucleoproteins, 
is  produced  in  the  body  and  from  food,  and  is  always  in  the  urine, 
being  one  of  its  normal  constituents.  It  is  only  when  this  sub- 
stance is  in  excess  in  the  urine  that  a  pathological  condition  is 
indicated. 

Examination  of  the  Urine,  then,  is  made  for  several  different 
purposes :  (1)  to  ascertain  whether  th6  kidneys  are  doing  their 
work  properly ;  (2)  to  find  if  the  kidneys,  or  any  part  of  the  urinary 
tract,  are  either  temporarily  or  permanently  diseased ;  (3)  to  be  able 
to  judge  from  the  various  substances  in  the  urine  whether  there  is 
any  abnormal  process  taking  place  in  the  body. 

Tests.  —  In  the  examination  of  the  urine  for  the  above  pur- 
poses, certain  definite  tests  are  made.  These  tests  differentiate 
between  the  abnormal  and  the  normal. 

(1)  Color. 

(2)  Amount  in  twenty-four  hours. 

(3)  Odor. 

(4)  Specific  gravity. 

(5)  Reaction,  acid  or  alkaline. 

(6)  Albumen,  indican,  acetone  bodies. 

(7)  Sugar. 

(8)  Microscopic  examination  for  casts,  cells,  bacteria,  etc. 

The  Color  of  normal  urine  varies,  especially  with  the  amount 
voided. 

The  variations  in  color  range  from  the  pale  straw  color  of  in- 
dividuals who  are  voiding  large  quantities  to  the  deep  lemon  or 
amber  of  those  who  void  much  less. 

Pathological  conditions  are  indicated  to  a  certain  extent  by  the 
color  of  the  urine.     Fevers  heighten  the  color,  small  quantities  of 


300  DIETETICS  FOR  NURSES 

blood  cause  a  smoky  appearance,  while  bile  changes  the  color  of 
the  urine  to  a  greenish  yellow. 

Precipitates  in  the  Urine.  —  When  the  urine  has  been  allowed 
to  stand  for  a  time  there  is  sometimes  a  brick-red  deposit  due  to 
the  precipitate  of  urates.  This  disappears  upon  heating  and  is 
not  an  evidence  of  any  diseased  condition. 

Turbidity  of  Urine.  —  The  turbidity  of  fresh  urine  then  is  the 
only  kind  which  need  be  considered,  since  standing  in  the  cold 
often  brings  about  this  condition,  due  to  the  growth  of  bacteria 
and  deposits  of  both  phosphates  and  urates. 

Requirements  in  Testing  Urine.  —  Urine  to  be  tested  should 
be  fresh,  and  when  it  is  not  possible  to  make  the  examination  at 
once  it  should  be  preserved  with  chloroform,  or  some  other  harm- 
less preservative,  until  ready  to  use. 

Bacteria  in  Urine.  —  The  changes  due  to  bacterial  growth  in 
the  urine  are  manifested  not  only  by  the  turbid  character  of  the 
urine  but  also  by  the  odor  of  ammonia. 

The  Amount  of  Urine.  —  The  amount  of  urine  voided  in  twenty- 
four  hours  varies  with  the  individual  in  health  as  well  as  in  dis- 
ease. Many  individuals  void  a  great  quantity  during  the  twenty- 
four  hours,  chiefly  because  they  drink  a  great  quantity  of  water 
and  other  beverages.  The  average  amount  of  urine  passed  in 
twenty-four  hours  by  an  adult,  or  a  child  over  eight  years,  is  from 
1000  to  2000  c.c.  It  represents  from  60  per  cent  to  70  per  cent  of 
the  amount  of  water  ingested. 

Collecting  the  Urine  for  Testing.  —  In  measuring  the  urine  it  is 
necessary  to  begin  collecting  it  after  the  bladder  has  been  emptied 
the  first  thing  in  the  morning.  The  patient  should  void  just 
before  the  end  of  the  twenty-four-hour  period  to  be  sure  that  the 
amount  formed  by  the  kidneys  during  this  time  is  accounted 
for. 

Diseases  in  Which  Urine  Is  Diminished.  —  In  certain  diseases 
the  amount  of  urine  passed  is  diminished.  This  is  found  to  be  true 
in  diarrhea  and  dysentery,  when  water  is  lost  in  the  feces  in 
hemorrhage  from  any  part  of  the  body  and  from  vomiting.  It  is 
likewise  at  times  the  case  after  abdominal  operations  and  in  ner- 


URINALYSIS  301 

vous  conditions,  such  as  hysteria.  The  urine  is  diminished  when 
there  is  an  organic  obstruction  in  the  urinary  tract  and  certain 
obstructive  diseases  of  the  heart,  'the  lungs  and  the  liver.  In 
these  latter  cases,  there  is  seen  to  be  a  retention  or  suppression  of 
urine.  In  both  acute  and  chronic  nephritis  and  in  certain  fevers, 
the  bladder  at  times  must  be  emptied  by  means  of  a  catheter. 
At  other  times,  the  condition  is  relieved  as  far  as  possible  by  limit- 
ing certain  articles  of  food  in  the  diet.  At  any  rate,  these 
points  must  be  kept  in  mind  when  examining  the  urine. 

Effect  of  Food  upon  the  Urine.  —  The  odor  of  normal  urine  is 
changed  after  eating  certain  foods,  such  as  onions  and  asparagus. 
In  disease,  the  odor  of  urine  has  a  distinct  value  as  a  means  of  diag- 
nosis ;  cystitis  gives  a  foul  odor,  certain  bacteria  bringing  about 
a  decomposition  in  the  urine  and  giving  rise  to  an  odor  of  putre- 
faction. In  cases  where  there  is  a  fistula  connecting  the  bladder 
and  rectum,  the  urine  has  a  fecal  odor. 

Specific  Gravity  of  Normal  Urine.  —  The  density  or  specific 
gravity  of  urine  means  the  weight  of  any  volume  of  urine  as  com- 
pared with  that  of  equal  volume  of  distilled  water.  The  specific 
gravity  of  normal  urine  varies  from  1.012  to  1.024,  that  is,  in  a 
thousand  cubic  centimeters  of  urine  there  are  found  from  11  to 
18  grams  of  solid  material.  In  health  it  is  necessary  to  know  the 
amount  of  urine  passed  in  twenty-four  hours,  to  be  able  to  judge 
whether  the  amount  of  solids  is  too  high  or  too  low. 

Specific  Gravity  of  Diabetic  Urine.  —  In  conditions  like  diabetes 
mellitus,  where  there  is  a  wastage  of  sugar  taking  place  in  the 
body,  that  is,  instead  of  being  oxidized  to  carbon  dioxide  and  water 
and  glucose,  the  sugar  is  passing  into  the  urine  without  completing 
its  oxidation.  The  specific  gravity  rises  in  these  cases  to  1030 
and  over,  showing  distinctly  that  a  greater  amount  of  solid  material 
is  in  the  urine  than  is  present  normally.  In  chronic  Bright's  dis- 
ease and  diabetes  insipidus,  the  specific  gravity  is  low. 

Method  of  Determining  Specific  Gravity.  —  The  specific  gravity 
is  determined  by  the  use  of  an  instrument  known  as  a  urinometer. 
The  urine  is  poured  into  a  tube  and  the  urinometer  is  dropped 
into  it.    The  different  figures  are  marked  upon  the  stem  of  the 


302  DIETETICS  FOR  NURSES 

instrument  and  it  is  a  simple  matter  to  read  off  the  figures  of  the 
level  to  which  the  stem  sinks. 

Reaction  to  Litmus.  —  In  a  former  chapter  it  was  stated  that 
normal  urine  was,  as  a  rule,  acid,  that  is,  it  turns  blue  litmus  red. 
Certain  diseases  render  the  urine  alkaline.  A  like  result  is  brought 
about  upon  the  ingestion  of  sodium  citrate  or  bicarbonate  of 
soda.  Urine  which  stands  and  becomes  decomposed  is  alkaline 
in  reaction,  due  to  the  bacterial  action,  with  the  production  of 
ammonia. 

Albumen  in  the  Urine.  —  The  presence  of  albumen  in  the  urine 
is  important,  since  normal  urine  does  not  contain  this  material  in 
quantities  sufficient  to  be  recognized  by  ordinary  tests.  Hence 
in  disease  its  presence  is  an  indication  of  pathological  processes 
taking  place  either  in  the  kidney  or  the  urinary  passages.  The 
chief  abnormal  condition  indicated  by  the  presence  of  albumen  in 
the  urine  is  nephritis.  Traces  of  albumen  may  occur  in  patients 
with  fever  or  a  heart  weakness.  Blood  and  pus  in  the  urine  like- 
wise indicate  albumen.  When  the  nephritic  condition  is  chronic, 
the  kidneys  themselves  are  diseased  and  the  presence  of  albumen 
may  be  in  traces  only,  while  during  the  acute  attack  large  quanti- 
ties may  be  passed,  but  the  urine  will  clear  up  after  a  time. 

TESTS  FOR  ALBUMEN 

The  heat  test  ^  is  the  simplest.  This  consists  of  first  filtering  the 
urine  through  filter  paper,  then  pouring  some  of  the  clear  urine 
into  a  test  tube,  holding  the  test  tube  in  a  flame  so  that  only 
the  upper  layer  boils,  then  adding  a  few  drops  of  2%  solution  of 
acetic  acid  and  boiling  again.  If  there  is  albumen  present,  a  very 
faint,  or  a  heavy  cloudiness  (precipitate  of  coagulated  albumen) 
forms  on  boiling  and  persists  or  becomes  heavier  on  the  addition 
of  a  few  drops  of  dilute  acetic  acid  (2%)  and  boiling  again.  If  a 
precipitate  occurs  at  the  first  boiling,  but  clears  up  again  entirely 
on  adding  acetic  acid,  it  is  not  albumen  but  harmless  phosphates 
or  carbonates. 

1  "  Chemistry  for  Nurses,"  by  Reuben  Ottenburg. 


URINALYSIS  303 


Into  a  test  tube  pour  a  few  drops  of  nitric  acid,  filter  the  urine 
and  allow  a  small  quantity  of  it  to  trickle  from  a  pipette  down 
the  side  of  a  test  tube  until  it  comes  in  contact  with  the  acid.  If 
albumen  is  present  a  distinctly  formed  white  ring  is  seen  at  the 
zone  of  contact. 

TEST  FOR  INDICAN 

This  material  is  found  in  cases  of  obstinate  constipation  and  in 
other  intestinal  disturbances  where  the  passage  of  the  food  mass 
in  the  small  intestines  is  delayed  and  the  putrefactive  bacteria 
exert  their  activities  upon  the  unabsorbed  protein. 

Test.  —  Mix  equal  quantities  of  urine  and  fresh  hydrochloric 
acid  and  add  drop  by  drop  fresh  concentrated  solution  of  chloride 
of  lime  (5  to  1000).  Indican  is  indicated  by  the  appearance  of  a 
blue  color. 

SUMMARY 

Urinalysis  represents  one  of  the  most  important  means  for 
determining  the  health  of  an  individual,  since  it  is  the  urine  that 
shows  those  substances  produced  in  the  body  as  a  result  of  the 
breaking  dowTi  of  the  body  tissues  and  protein  foods. 

Composition  of  Normal  Urine  must  be  familiar  to  the  nurse 
in  order  that  she  may  recognize  any  change  taking  place  in  the 
urine  of  her  patient  which  may  indicate  pathological  conditions  in 
the  body. 

The  Specific  Gravity  of  urine  is  one  of  the  points  by  means 
of  which  the  presence  of  certain  substances  more  or  less  abnormal 
in  character  is  determined. 

Other  Points,  such  as  color,  odor,  quantity,  reaction,  and 
chemical  composition,  likewise  show  any  deviation  from  the  nor- 
mal in  the  individual. 

Urine  Tests  are  necessary  to  determine  the  composition  of  the 
secretion.  The  character  of  these  tests  and  the  methods  used  in 
making  them  form  an  essential  part  in  the  training  of  the  nurse." 


304  DIETETICS  FOR  NURSES 

Tests  for  the  presence  of  albumen,  sugar,  and  possibly 
indican  in  the  urine,  should  be  made  by  the  nurse.  The  latter 
substance  represents  the  extent  of  putrefaction  taking  place  in  the 
body  and  for  this  reason  should  be  included  in  the  urine  tests. 

Collecting  the  Urine  for  testing  is  important.  The  amount 
includes  all  that  has  been  voided  throughout  the  entire  twenty- 
four  hours  beginning  after  the  bladder  has  been  emptied  on  the 
first  morning  and  ending  after  the  first  specimen  has  been  voided 
on  the  morning  of  the  second  day. 

Preserving  the  Urine  for  testing  is  usually  necessary,  espe- 
cially during  the  warm  weather.  The  specimens  should  be  col- 
lected in  a  wide-mouthed  sterile  glass  jar.  This  should  be  kept 
in  a  cold  place.  Some  harmless  preservative  such  as  chloroform 
should  be  added  to  assure  its  keeping. 


CHAPTER  XX 
ACUTE  AND  CHRONIC  NEPHRITIS 

Nephritis  h  sl  disease  of  the  kidneys,  in  which  changes  occur  in 
the  tissues  of  the  organs  themselves ;  these  changes  may  be  caused 
by  inflammation  of  the  kidneys  and  renal  passages  brought  on  as 
results  of  the  retention  of  certain  poisonous  substances  in  the  blood, 
or  from  the  action  of  specific  bacteria.  The  disease  may  be  acute 
or  chronic  in  form  and  develop  as  a  result  of  prolonged  exposure 
to  cold  and  wet,  of  tonsillitis,  scarlet  fever,  typhoid  fever,  and  to  a 
less  extent  of  malaria,  syphilis,  pregnancy,  and  tuberculosis,  as 
well  as  from  the  effects  of  certain  irritating  drugs,  such  as  can- 
tharides  and  turpentine. 

Directing  the  Treatment.  —  In  any  case  the  treatment  must  be 
directed  toward  the  relief  of  the  acute  symptoms  in  the  beginning 
and  followed  up  by  a  general  treatment  which  will  tend  to 
strengthen  and  relieve  the  overtaxed  organs  and  to  increase  their 
power  to  functionate  normally. 

Causes  and  Effects.  —  In  acute  nephritis,  the  chief  symptoms 
are  uremia  and  edema;  the  urine  is  materially  diminished  in 
quantity  and  at  times  suppressed ;  it  is  often  found  to  be  rich  in 
albumen  and  containing  hyaline  and  blood  casts,  red  and  white 
blood  cells,  and  various  pigments. 

In  chronic  nephritis,  which  may  be  the  result  of  an  acute  attack, 
or  as  a  sequel  of  other  diseases  already  mentioned,  there  is  seen 
to  be  a  progressive  loss  of  flesh  and  strength,  marked  anemia, 
gastro-intestinal  disturbances,  increased  blood  tension  and  edema, 
the  latter  especially  in  the  face  on  arising  in  the  morning.  Uremia 
may  develop  at  any  time. 

Limiting  the  Work  of  the  Kidneys.  —  In  both  acute  and  chronic 
nephritis,  great  effort  must  be  put  forth  to  relieve  the  tax  upon 
the  kidneys  and  to  stimulate  their  functioning  power. 

In  other  diseases,  in  which  definite  organs  are  involved,  the 
treatment  consists  chiefly  of  resting  the  affected  parts  (1)  by  star- 
X  305 


306  DIETETICS  FOR  NURSES 

vation,  (2)  by  deflecting  the  work  to  other  organs  when  it  is  pos- 
sible, chiefly  by  changing  the  diet  until  the  disturbance  is  overcome. 
This  is  generally  effectual  in  most  cases,  as  has  been  specially 
demonstrated  in  the  treatment  of  gastro-intestinal  diseases. 

Problems  to  Be  Considered.  —  But  in  nephritis,  there  are  other 
problems  to  consider,  which  make  it  impossible  to  institute  such 
a  treatment  which  will  effect  a  perfect  rest  of  the  renal  organs. 
The  kidneys  represent  the  chief  source  whereby  the  waste  products 
of  the  body  are  eliminated.  This  waste  consists  not  only  of  the  end- 
products  of  the  nitrogenous  foods  ingested,  but  also  the  end  prod- 
ucts of  tissue  metabolism,  which  is  the  inevitable  result  of  the 
wear  and  tear  of  life.  Hence,  when  the  functions  of  the  kidneys 
are  disturbed,  these  products,  often  toxic  in  character,  are  re- 
tained instead  of  excreted.  Thus  instead  of  forming  normal  con- 
stituents of  the  urine  they  find  their  way  into  the  general  circu- 
lation, exerting  a  damaging  effect  upon  the  tissues,  especially  of 
the  kidneys  with  which  they  are  brought  into  such  direct  contact. 

Substances  Difficult  of  Excretion.  —  It  has  been  proved  that 
the  kidneys  in  nephritis  find  it  diflScult  to  excrete  certain  sub- 
stances, namely,  urea,  water,  salts,  and  the  purin  bodies.  Many 
authorities  claim  that  the  uremia  manifested  in  acute  nephritis 
is  the  result  of  the  retention  of  end-products  of  the  protein  me- 
tabolism already  mentioned  and  that  the  edema  is  due  to  a  like 
retention  of  water  and  salts.  The  greatly  diminished  quantity  of 
urine  voided  during  the  acute  attack  would  seem  to  prove  this 
theory.  Martin  Fisher,^  however,  claims  the  condition  to  be  due 
to  an  acidulation  of  the  tissues  with  a  consequent  osmosis  of  water, 
and  directs  his  treatment  to  overcome  this  condition,  not  by 
restricting  the  quantity  of  water  and  salt,  as  is  generally  practiced, 
but  by  injecting  a  saline  solution  into  the  body  in  large  quantities 
with  the  effect  of  increasing  the  flow  of  urine  by  concentrating 
the  salt  content  of  the  blood  and  therefore  its  osmotic  power. 
The  fluids  are  withdrawn  from  the  tissues,  thus  adding  fluidity 

1  Fisher's  Solution. 

Sodium  carbonate  (pure  crystals) 14 

Sodium  chloride 10 

Water 1000 


ACUTE  AND  CHRONIC  NEPHRITIS  307 

to  the  blood  stream,  which  in  turn  flushes  the  kidneys,  ridding 
them  of  the  poisons  which  interfere  with  their  normal  functioning. 

Adjusting  the  Diet.  —  The  uremia  and  edema  must  be  relieved. 
Since  it  is  an  undisputed  fact,  in  the  majority  of  cases,  that  good 
results  from  the  regulating  of  the  diet  so  as  to  minimize  as  far  as 
possible  the  work  of  the  kidneys,  the  various  diet  cures  will  be 
included  here. 

Milk  Cure.  —  Milk,  as  a  rule,  forms  a  basis  of  most  of  the 
nephritic  diets  chiefly  because  of  its  low  salt  and  protein  content 
and  on  account  of  its  non-toxic  end-products. 

The  percentage  of  water  in  milk  is  likewise  known  and  for  this 
reason  the  fluid  content  of  a  milk  diet  can  be  easily  calculated. 
However,  it  is  also  true  that  the  greatest  drawback  to  a  diet  con- 
sisting solely  of  milk  is  the  large  amount  of  water  therein  compared 
with  its  nutrient  value. 

Resting  the  Kidneys.  —  During  the  acute  stage  of  nephritis  the 
kidneys  are  given  as  much  rest  as  possible  by  eliminating  all 
food  and  restricting  the  amount  of  water  entering  the  body.  The 
thirst  is  relieved  by  small  sips  of  plain  or  carbonated  water  or  by 
ice  pellets  held  in  the  mouth,  or,  as  is  sometunes  necessary,  by  in- 
jections of  water  into  the  rectum. 

Adjusting  the  Fluids.  —  The  amount  of  fluid,  however,  must  be 
adjusted  to  meet  the  condition  of  the  patient,  taking  into  con- 
sideration the  amount  of  urine  voided  and  the  uremic  symptoms 
manifested.  If  the  urine  is  not  suppressed  the  amount  of  water 
taken  may  be  slightly  in  excess  of  the  urine  voided,  thus  promot- 
ing diuresis.  In  many  cases  an  excellent  diuretic  drink  consisting 
of  one  pint  of  water  and  one  teaspoonful  of  cream  of  tartar  with 
a  half  a  lemon  and  perhaps  a  little  sugar,  serves  the  purpose  of 
relieving  the  thirst,  which  is  at  times  acute  during  this  period. 

The  extent  of  the  starvation  treatment  must  depend  upon  the 
patient  himself.  As  a  rule,  however,  it  is  not  carried  out  longer 
than  two  days,  after  which  milk  may  be  substituted,  allowing  from 
twenty  to  thirty  ounces  per  day,  which  is  as  much  fluid  as  an  ordi- 
nary nephritic  patient  can  handle. 

The  regulation  nephritic  diet,  which  is  bland  in  character,  con- 


308 


DIETETICS   FOR  NURSES 


tains  nothing  that  will  tend  to  increase  the  irritation  and  inflam- 
mation of  the  kidneys,  and  furnishes  a  certain  amount  of  nourish- 
ment when  the  symptoms  of  the  disease  warrant  the  giving  of 
any  food  other  than  milk. 

Available  Foods.  —  The  following  table  of  foods  may  be  used 
unless  gastro-intestinal  disturbance  makes  it  inadvisable.  The 
food  materials  in  this  table  are  poor  in  salt  and  protein.  Lactose 
has  been  advised  as  a  means  of  increasing  the  energy  contents  of 
the  dietary  and  is  less  irritating  than  sucrose  (cane  sugar)  and 
may  be  added  to  cereals,  milk,  cocoa,  fruit,  and  fruit  beverages-: ' 

TABLE 

Vegetables 

Potatoes  (white,  baked,  mashed,  or 
creamed  with  butter) 

Sweet  potatoes,  baked,  with  butter 

Green  vegetables 

String  beans 

Spinach 

Greens    (mustard,    turnips,   or   beet 
greens) 

Desserts 

Rice,     tapioca     and     corn     starch 
pudding 

Cornstarch  blancmange,  with  cream 
Fruits 

Oranges,   lemons,   grapefruit,   bana- 
nas, prunes,  and  canned  fruits 

The  following  schedule  by  Doctors  Chase  and  Rose  shows  how 
the  nephritic  diet  may  be  arranged : 


Milk 
Cocoa 
Fruit  juices 

Cereals 
Farina 

Cream  of  wheat 
Wheatena 

Ralston's  Health  Food 
Oatmeal  (occasionally) 
Rice 

Dry  toast,  milk  toast 
Cream  toast,  buttered  toast 


OUTLINE    OP   DIETS  2 

Noon 

Cream  soup 

Plain  rice,  celery 

Potato,      spinach,      as- 
paragus 

Chief  vegetables,  white 
potato,  baked  or 
mashed  with  butter, 
sweet  potato,  banana 

Lettuce  salad,  with  oil 

Cocoa 

'Table    by    Arthur   F.  Chase  and    Anton   R.    Rose.     "The   Journal    of   The 
American  Medical  Association,"  Vol.  LXIX,  No.  6,  p.  441. 


Morning 
Citrus  fruit 
Cereal : 

Farina,   oatmeal, 
banana 
Cream  toast 
Beverage 


Evening 

Rice,  steamed,  with 
cream  or  baked 
banana,  or  as  pud- 
ding 

Cornstarch  blancmange 
and  cream 

Banana  and  milk 


ACUTE  AND   CHRONIC  NEPHRITIS  309 

Doctors  Chase  and  Rose  advise  farina  used  more  frequently  than 
oatmeal,  and  the  plain  cream  soup,  rice  or  potato,  more  often  than 
soups  made  of  celery  or  asparagus  (the  latter  used  to  break  the 
monotony).  They  also  advise  the  more  frequent  use  of  green 
string  beans  and  asparagus  in  preference  to  other  vegetables. 

Elimination  of  Salt.  —  In  many  cases  of  nephritis,  especially 
those  belonging  to  the  parenchymatous  type,  the  kidneys  manifest 
a  difficulty  in  eliminating  salt,  and  instead  of  excreting  the  normal 
quantity,  find  it  impossible  to  eliminate  more  than  two  or  three 
grams  or  less  a  day.  The  retained  salts  pass  into  the  fluids  of 
the  tissues,  giving  rise  to  or  increasing  the  already  existing  edema. 
Tests  ^  have  been  devised  to  find  the  extent  of  the  kidney  function 
to  excrete  salt.  The  following  diets  are  among  those  commonly 
used :  ^ 

3  litres  of  milk  (this  contains  5  gm.  sodium  chloride  and  100  gm.  protein) 

or 
Strauss  Diet,  consisting  of  f  litre  milk,  4  eggs,  150  gm.  bread,  and  enough 

fruit  and  fruit  juice,  tea  and  sugar  to  make  it  palatable.     (This  diet 

contains  about  3  gm.  of  salt.) 

If  the  kidneys  are  able  to  excrete  the  amount  of  salt  contained 
in  these  diets,  salt  may  be  added  in  quantities  of  from  5  to  10 
grams. 

Salt-poor  Diets.  —  When  the  kidneys  are  unable  to  eliminate 
the  normal  amount  of  salt,  some  of  the  salt-poor  diets  should  be 
advised.  Coleman  claims,  ^  however,  that  these  diets  have  not  ful- 
filled the  promises  held  out  by  them.  Coleman  groups  the  salt- 
poor  diets  under  three  headings  : 

(1)  The  strict  salt-poor  diet,  of  which  Widal's  diet  is  an  example. 

(2)  The  medium  strict  salt-poor  diet,  allowing  from  2.5  to  5 
grams  of  salt  a  day.  Under  this  heading  the  milk  diet  was  placed, 
in  which  2  to  3  grams  of  salt  is  served  a  day  at  table. 

(3)  The  moderate  salt-poor  diet,  in  which  from  5  to  10  grams  of 
salt  are  allowed  each  day.  In  using  this  diet  it  is  not  necessary 
to  prepare  a  special  menu  for  the  patient,  but  take  precautions  to 

'  For  more  extensive  lists  see  Table  of  "Ash  Constituents  of  Common  Food," 
pp.  16-17. 

*  •'  Journal  of  Internal  Medicine, "  Vol.  XIV,  1914.  « Ibid. 


310  DIETETICS  FOR  NURSES 

leave  the  salt  shaker  off  the  tray  and  exclude  bacon,  ham,  and  other 
salty  foods  from  the  dietary. 

Limiting  the  Amount  of  Food.  —  It  must  be  kept  in  mind  that 
the  nephritic  condition  makes  it  imperative  to  fall  below  rather 
than  exceed  the  food  requirements  of  the  individual. 


widal's  diet^ 

Salt-free  bread 

200  gm. 

Meat  (beef,  chicken,  or  mutton) 

200  gm. 

Vegetables  (beans  or  rice)  salt  free 

250  gm. 

Butter,  salt  free 

50  gm. 

Sugar 

40  gm. 

Contains  60  grams  of  protein,  1  to  2  grams  of  NaCl,  and  fur- 
nishes approximately  1500  calories. 

Strouse  and  Perry  arranged  a  dietary  from  the  above  diet  as 
follows : 

8  A.M.  Bread,  60  grams ;  lamb  chop,  50  grams ;  butter,  10 
grams ;  rice,  100  grams ;  sugar,  40  grams. 

12  M.  Bread,  60  grams ;  roast  beef,  100  grams ;  butter,  20 
grams ;  beans,  150  grams. 

5.  P.M.    Bread,  80  grams ;  butter,  20  grams ;  chicken,  50  grams. 

halpin's  salt-free  nephritic  diet^ 

Milk,  1500  to  2000  c.c,  white  salt-free  bread,  400  to  500 
grams ;  salt-free  butter,  40  grams ;  eggs,  4  to  6.  This  diet  con- 
tains from  5  to  6  grams  of  salt. 

KARELL  CURE 

Karell  has  devised  the  milk  cure,  which  is  used  possibly  more 
than  any  other  diet.  It  not  only  furnishes  a  dietary  regime, 
which  is  used  in  nephritis,  but  it  is  likewise  advocated  in  organic 
diseases  of  the  heart  and  blood  vessels. 

Methods  of  Administering  the  Karell  Cure.  —  The  cure  is  begun 
by  giving  from  3  to  6  ounces  of  milk  three  or  four  times  a  day. 
Karell  makes  a  point  of  using  small  quantities  to  begin  with  and 
having  the  milk  skimmed.    The  milk  is  given  at  regular  intervals, 

•  "Food  for  the  Sick,"  p,  108,  by  Strouse  and  Perry. 


ACUTE  AND   CHRONIC  NEPHRITIS  311 

is  warmed  in  winter  and  given  at  room  temperature  in  the  summer. 
It  may  be  given  plain  or  diluted  with  limewater.  After  a  week  if 
the  stools  remain  solid,  the  daily  allowance  of  milk  is  increased  to 
two  quarts.  Constipation  is  an  indication  of  the  agreement  of 
this  diet  and  the  patient's  utilization  of  the  milk.  If,  however, 
he  manifests  gastro-intestinal  disturbances,  resulting  in  diarrhea, 
the  amount  must  be  temporarily  reduced.  Karell  advocates  boil- 
ing the  milk  and  relieving  the  constipation  with  enemas  or  mild 
laxatives.  The  addition  of  small  quantities  of  coffee  to  the  morn- 
ing portion  of  milk,  or  of  stewed  prunes  or  a  baked  apple  to  the 
afternoon  feeding,  also  tends  to  overcome  the  condition. 

Thirst.  —  The  extreme  thirst  may  be  relieved  by  adding  plain 
water,  limewater,  or  seltzer  to  the  feedings. 

If  during  the  second  or  third  week  of  the  cure  the  hunger  be- 
comes too  great  for  the  patient  to  endure,  a  small  piece  of  herring 
or  stale  bread  may  be  given. 

Once  a  day  a  milk  soup  thickened  with  a  cereal  may  be  given. 
The  above  diet  is  carried  out  from  five  to  six  weeks,  after  which 
the  patient  is  gradually  returned  to  a  normal  diet.  Milk,  however, 
should  still  constitute  an  important  part  of  the  diet.  The  Karell 
Cure  is  modified  more  or  less  to  meet  the  condition  of  the  patient, 
the  amount  of  milk  administered  in  some  cases  being  more  and 
in  others  considerably  less  than  mentioned  in  the  above  regime. 

Limiting  the  Proteins.  —  The  extent  of  the  damage  caused  by 
the  end-products  of  protein  metabolism  cannot  be  easily  estimated, 
but  it  is  wise  not  to  err  on  the  side  of  an  over-supply,  since  the  re- 
taining of  these  materials  in  the  body  gives  rise  to  a  certain  type 
of  intoxication  (uremic  poisoning). 

Relative  Toxicity  of  the  Animal  Proteins.  —  The  difference 
between  the  various  animal  proteins  as  to  their  relative  toxicity 
has  been  the  subject  of  much  discussion.  As  far  as  their  nutrient 
value  is  concerned,  they  are  practically  the  same,  that  is,  the  pro- 
tein of  beef  and  the  protein  of  chicken  show  very  similar  analyses. 
The  beef  contains,  however,  more  extractives,  which  we  know  are 
high  in  purins.  These  substances  have  proven  detrimental  to  the 
welfare  of  a  nephritic  patient. 


312  DIETETICS  FOR  NURSES 

Selection  and  Preparation  of  Foods.  —  For  this  reason  the  so- 
called  red  meat  is  sometimes  boiled  instead  of  roasted,  as  the  latter 
mode  of  preparation  increases  the  formation  of  purins  on  the  brown 
outer  surfaces  of  the  meat.  Chicken  and  fish  contain  less  purin 
bases  and  for  this  reason  are  often  included  in  the  diet  when  beef- 
steak and  lamb  chops  are  excluded.  Meat  soups  and  broths  con- 
tain little  nutrient  value,  consisting  as  they  do  chiefly  of  water, 
salt,  and  extractives,  all  of  which  are  looked  upon  with  disfavor, 
and  classed  with  the  offending  articles  of  food  in  the  nephritic  diet. 
Cream  soups,  except  bean  or  pea  soup,^  may  be  given  in  modera- 
tion. They  are  non-toxic  in  character  and  of  high  nutrient  value, 
furnishing  a  valuable  addition  to  the  diet  when  the  gastro-intes- 
tinal  symptoms  permit  of  such  addition. 

CONVALESCENT  NEPHRITIC  DIET  ^ 

Advisable  Foods.  —  The  following  foods  are  used  in  the  forma- 
tion of  diet  for  an  advanced  convalescent  nephritic  patient  when 
not  otherwise  contra-indicated : 

Cereals,  potatoes,  rice,  green  vegetables  and  salads,  fruits, 
fresh  and  stewed,  ham,  bacon,  or  beef  ^  once  or  twice  a  week, 
chicken,  lamb,  or  mutton  •  several  times  a  week,  simple  desserts, 
such  as  junket,  prune  or  fig  whip,  orange,  lemon,  grape,  pineapple, 
or  apricot  gelatine,  bread,  rice,  or  tapioca  pudding,  plain  vanilla 
ice  cream.^° 

Foods  to  Be  Avoided.  —  The  following  foods  are  avoided  except 
the  meats,  which  must  be  given  not  more  than  once  to  three  times 
a  week,  as  directed  by  physician : 

Meat  broths,  especially  those  made  from  commercial  meat 
extracts,  bouillon  cubes,  etc. 

Strong  tea  or  coffee. 

Alcoholic  beverages,  unless  especially  prescribed  by  the  physician. 

'  Beans  and  peas  belong  to  the  class  of  foods  known  as  legumes,  which  are  high 
in  protein  and  must  be  treated  as  any  other  protein  food. 

8  Author's  list  and  diet  sheets. 

'  Meats  of  all  sorts  should  be  boiled,  or  only  the  inside  portions  allowed. 

^°  Some  physicians  exclude  ice  cream  from  the  diet,  while  others  permit  a  small 
portion,  provided  it  is  not  so  rich  as  to  cause  digestional  disturbances. 


ACUTE  AND   CHRONIC  NEPHRITIS  313 

Liver,  kidney,  sweetbreads." 

Meat  croquettes  and  other  made  dishes. 

Rich  sauces  or  gravies. 

Condiments  and  spices  of  all  sorts. 

Rich  pastries. 

The  salt  must  be  limited  and  water  and  other  fluids  restricted. 

Sample  Diet  Sheets.  —  The  following  menus  ^^  formulated  from 
the  above  diet  list  are  suggested  : 

No.  1.  —  8  A.M.  Sliced  oranges,  cream  of  wheat  with  cream, 
buttered  toast,  cocoa. 

10  :  30  A.M.     6  ounces  of  milk  with  crackers. 

12:30  P.M.  Cream  of  spinach  soup,  rice,  string  beans,  orange 
gelatine,  bread  and  butter. 

3  P.M.     6  ounces  of  buttermilk  with  crackers. 

6  P.M.  Cereal  and  cream,  baked  potato,  apple  sauce,  cocoa, 
bread  and  butter. 

No.  2.  —  8  A.M.  Stewed  prunes,  wheatena  and  cream,  milk  or 
dry  toast  with  butter,  cocoa. 

10 :  30  A.M.  6  ounces  of  malted  milk  with  crackers  or  1  slice  of 
zwieback. 

12  :  30  P.M.  Cream  of  corn  soup,  mashed  potatoes,  beet  tops  or 
mustard  greens,  lettuce  salad,  dressing  made  with  lemon  juice  and 
olive  oil,  rice  pudding. 

3  P.M.     6  ounces  of  orange  or  grape  juice  with  crackers. 

6  P.M.     Cream  toast,  sliced  peaches,  cocoa. 

No.  3.  —  8  A.M.  Half  a  grape  fruit,  farina  and  cream,  toast 
and  butter,  cocoa. 

10 :  30  A.M.     6  ounces  of  buttermilk  with  crackers. 

12 :  30  P.M.  Cream  of  tomato  soup,  creamed  potatoes,  buttered 
beets,  celery  salad,  apple  tapioca  pudding,  bread  and  butter. 

3  P.M.     6  ounces  of  milk  with  crackers. 

6  P.M.  Ralston's  Health  Food  with  cream,  baked  potato, 
tomato  salad,  toast  and  butter,  cocoa. 

11  Boiled  sweetbreads  are  sometimes  allowed,  but  should  never  be  given  without 
the  advice  of  a  physician. 

1^  The  preparation  of  the  menus  requires  care  and  attention,  meal  must  be 
small  and  all  fried  foods  avoided. 


314  DIETETICS  FOR  NURSES 

No.  4.  —  8  A.M.  Stewed  prunes,  grits  and  cream,  toast  and 
butter,  cocoa. 

10  :  30  A.M.     6  ounces  of  malted  milk  with  crackers. 

12 :  30  P.M.  Cream  of  asparagus  soup,  creamed  cauliflower, 
boiled  rice,  lettuce  salad,  bread  and  butter,  pineapple  gelatine. 

3  P.M.     6  ounces  of  orange  juice  with  crackers  or  zwieback. 

6  P.M.  Creamed  toast,  escalloped  potatoes,  fruit  salad,  toast, 
cocoa,  and  cocoa  junket. 

CHRONIC  NEPHRITIS    (bRIGHt's  DISEASE) 

Chronic  nephritis  may  develop  as  a  sequel  to  an  acute  attack, 
and  an  individual  suffering  from  chronic  nephritis  may  at  any 
time  develop  acute  symptoms.  In  any  case  the  dietetic  treat- 
ment would  necessarily  have  to  be  made  to  cover  the  existing 
symptoms. 

Dietetic  Treatment.  —  In  cases  where  the  patient  has  entirely 
recovered  from  uremia  but  still  manifests  symptoms  of  water  and 
salt  retention,  the  diet  would  be  naturally  directed  to  cover  the 
latter,  at  the  same  time  taking  care  not  to  strain  the  weakened 
functions  by  giving  more  food  than  could  be  readily  handled. 
The  water  and  salts  still  have  to  be  restricted,  but  a  certain  amount 
of  fat  and  carbohydrate  with  small  additions  of  nitrogenous  food 
materials  may  be  added  from  time  to  time  as  the  kidneys  show 
improvement.  It  must  be  borne  in  mind,  however,  that  at  this 
time  it  is  very  easy  to  overtax  the  renal  organs  and  it  is  safer  to 
err  on  the  side  of  under  rather  than  over  feeding. 

The  logical  treatment,  therefore,  consists  of  utilizing  the  im- 
proved functions  while  those  still  failing  to  react  are  getting  further 
rest. 

Adjusting  the  Proteins  in  Diet.  —  If  the  individual  shows  a 
definite  anemia,  as  is  often  the  case  after  acute  attacks,  either  as 
a  result  of  the  disease  itself  or  the  necessarily  low  diet,  which  the 
acute  symptoms  of  uremia  and  edema  made  necessary,  other 
measures  are  necessary  to  bring  the  body  back  to  a  normal  condi- 
tion.    It  has  been  found  that  in  these  cases  where  there  has  been 


ACUTE  AND   CHRONIC  NEPHRITIS  315 

no  permanent  damage  to  the  renal  organs,  but  merely  a  temporary 
impairment  of  the  functioning  power,  the  treatment  must  be, 
first,  a  rest  to  the  affected  parts ;  second,  the  temporary  restric- 
tion of  all  articles  of  food  which  impose  a  tax  on  the  kidneys  to 
eliminate;  the  third,  the  gradual  return  to  normal  diet  as  the 
acute  symptoms  decrease  and  the  function  of  the  kidneys  no  longer 
shows  impairment.  Such  a  case  is  cited  by  Strouse  and  Perry  ^^  as 
occurring  in  the  Michael  Reese  Hospital.  Mr.  X.  recovered  from 
the  acute  stage  of  nephritis  and  all  signs  of  edema  and  uremia 
disappeared ;  the  man  was  kept  on  a  low  salt  and  low  protein 
diet  for  a  long  time.  His  urine  was  clearing  up,  but  he  did  not 
feel  up  to  standard  and  remained  anemic.  Thinking  in  all  prob- 
ability that  his  symptoms  were  due  to  a  low  protein  diet,  meat 
was  slowly  added  to  his  dietary  until  he  was  receiving  60  grams 
of  protein  a  day.  There  was  an  immediate  general  improvement 
in  his  condition  with  no  increased  renal  disturbance.  It  is  an 
obvious  fact  that  chronic  nephritis,  like  any  other  chronic  condi- 
tion, requires  a  different  method  of  treatment  from  that  practiced 
to  relieve  the  acute  stage.  The  very  fact  that  it  is  chronic  proves 
that  the  strenuous  methods  are  neither  necessary  nor  wise. 

Testing  the  Kidney  Functions.  —  The  authorities  of  to-day  en- 
deavor to  ascertain  the  extent  of  the  damage  to  the  renal  organ 
by  testing  its  functioning  power.  These  renal  function  tests  have 
been  the  subject  of  much  interest  and  investigation.  Probably 
the  ones  most  commonly  employed  are  those  devised  by  Hedinger 
and  Schlayer  ^'*  and  adapted  for  use  in  the  Johns  Hopkins  Hospital 
by  Mosenthal. 

Diets  Used  in  Tests.  —  The  diet  employed  in  making  these 
tests  consists  of  different  amounts  of  certain  substances  known  to 
be  diuretic  in  character.  This  diet  is  rigidly  adhered  to  and  a 
careful  analysis  of  the  urine  passed,  the  total  quantity  and  specific 
gravity  of  each  specimen  made  and  in  this  way  the  various  func- 
tions of  the  kidneys  and  the  impairment  thereof  are  tested.  Thus 
an  intelligent  adjustment  of  the  diet  may  be  made. 

"  "Food  for  the  Sick,"  p.  112,  Strouse  and  Perry. 
li  "Medical  Clinics  of  Chicago,"  Vol.  II,  No.  5,  1917. 


316 


DIETETICS  FOR  NURSES 


Renal  Functional  Tests.  —  The  following  schedule  is  used  by 
Mosenthal,  of  the  Johns  Hopkins  Hospital/^  in  making  what  is 
known  as  the  '*  Two-Hour  Test  for  Renal  Function  " : 


HEDINGER-SCHLAYER-MOSENTHAL  DIET  ^^ 

Date 


For 

All  foods  to  be  salt  free  from  the  diet  kitchen,  salt  for  each  meal 
will  be  furnished  in  weighed  amounts.^^ 

All  foods  or  fluids  not  taken  must  be  weighed  or  measured  after 
each  meal  and  charted  in  spaces  below.  Allow  no  food  or  fluid 
at  any  time  except  at  meal  times. 

Note  any  mishaps  or  irregularities  that  occur  in  giving  the  diet 
or  collecting  the  specimens. 
Breakfast  8  a.m.     Boiled  oatmeal 100  grams 

Sugar  1  to  2  teaspoonfuls 

Milk 30  c.c. 

2  slices  of  bread 30  grams  each 

Butter 20  grams   , 

Coffee  160  c.c.  ] 

Sugar  1  teaspoonful  >      .     .     .     200  c.c. 

Milk  40  c.c.               J- 
Dinner  —  Noon     Meat  soup 180  c.c. 

Beefsteak      .     : 100  grams 

Potatoes,    boiled,    mashed    or 
baked 130  grams 

Green  vegetables  as  desired 

2  slices  bread  —  each      ...     30  grams 

Butter 20  grams 

Tea,  180  c.c. " 

Sugar,  1  tsp.      .     .     .     ,\  .     .     200  c.c. 

Milk,  20  c.c. . 

Water 250  c.c. 

Pudding,  tapioca  or  rice      .    '.     110  grams 

IS  Copied  from  "Medical  Clinic  of  Chicago,"  Vol.  II,  No.  5,  1917. 

"  NaCl,  2  to  3  grams  in  a  capsule  accompanying  each  meal.  Any  salt  unused 
is  returned  to  the  diet  kitchen,  where  it  is  weighed  and  the  amount  used  is  indicated 
on  the  chart. 


ACUTE  AND  CHRONIC  NEPHRITIS 


317 


Supper  5  P.M.         2  eggs  cooked  any  style 

2  slices  of  toast      .....     30  grams  each 

Butter 20  grams 

Tea,.  180  c.e.  1 

Sugar,  1  tsp. 200  grams 

Milk,  20  c.c. . 

Fruit,  stewed  or  fresh     ...     1  portion 

Water 300  c.c. 

8  A.M.  No  food  or  fluid  is  to  be  given  during  the  night  or  until 
8  o'clock  next  morning  (after  voiding)  when  the  regular  diet  is 
resumed. 

Patient  is  to  empty  the  bladder  at  8  a.m.  and  at  the  end  of  each 
period  as  indicated  below.  The  specimens  are  to  be  collected  for 
the  following  periods  in  properly  labeled  bottles : 

8  a.m.  to  10  A.M.;  10  A.M.  to  12  Noon;  12  Noon  to  2  p.m.; 
2  P.M.  to  4  P.M. ;  4  P.M.  to  6  p.m.  ;  6  p.m.  to  8  p.m.  ;  8  p.m.  to  8 

A.M. 

Chart  Used  in  Johns  Hopkins  Hospital. — The  following  chart 
is  inserted  here  to  show  the  method  used  in  the  Johns  Hopkins 
Hospital  for  carrying  out  the  Two-hour  Renal  Test : 


Urine 

NaCl 

Nitrogen 

Time  of  Day 

C.  C. 

Specific 
Gravity 

Per  cent 

Grams 

Per  cent 

Grams 

8  A.M.-IO  A.M. 

10  A.M.-12  Noon 
12  Noon-2  P.M. 

2  P.M.-4  P.M.       . 
4  P.M.-6  P.M.       . 
6  P.M.-8  P.M.       . 
8  P.M.-8  A.M.        . 

Total  day     .     . 
Night  8  P.M.  to 

8  A.M.     .       .       . 

Total  24  hours 
Intake  of  fluid 
NaCl  .... 

7 

A.M. 

10 

A.M. 

12: 
4 

30 

P.M. 
P.M. 

7 

P.M. 

318  DIETETICS  FOR  NURSES 

Urine  to  be  collected  punctually  every  two  hours  and  kept  in 
the  ice  box,  every  specimen  having  twenty  drops  of  tutuol  added 
to  insure  preservation. 

Another  modification  of  the  Hedinger-Schlayer  diet  is  used  in 
the  Peter  Bent  Brigham  Hospital/^  Boston,  Massachusetts,  as 
follows : 

Coffee,  milk,  sugar,  toast,  and  butter. 

Milk,  toast,  and  butter. 

Bouillon,  broiled  steak,  butter,  mashed  potatoes, 
toast,  coffee,  milk,  sugar. 

Tea,  milk,  sugar,  crackers. 

Soft  egg,  blancmange  (1  egg,  sugar,  cornstarch,  and 
milk)  and  cream.  Amounts  sufficient  to  give 
2500  calories,  1500  c.c.  fluid,  76  grams  of  protein, 
127  grams  of  fat,  245  grams  of  carbohydrate, 
and  from  5  to  8  grams  of  sodium  chloride. 

On  two  days  previous  to  the  test  the  patient  usually  had  a 
diet  containing  2000  calories,  75  grams  of  protein,  4  grams  of 
sodium  chloride. 

The  test  diet  is  a  mixed  diet  containing  known  amounts  of  water, 
nitrogen,  and  chloride,  together  with  the  food  diuretics  (purins, 
salt,  and  water),  as  can  be  seen.  The  diet  is  divided  into  unequal 
portions  containing  known  but  varying  amounts  of  fluid,  nitrogen, 
and  salt.  Two-hour  specimens  are  collected  from  7  a.m.  to  9 
P.M.,  and  one  night  specimen  is  obtained  containing  all  the  urine 
passed  between  9  p.m.  and  7  a.m.  Each  specimen  is  analyzed  for 
volume,  specific  gravity,  total  nitrogen,  nitrogen  concentration, 
total  chloride,  and  chloride  concentration. 

Purpose  of  Tests.  —  The  purpose  of  the  test  is  to  find  out  to 
what  extent  and  in  what  manner  the  diseased  kidney  under  stimu- 
lation by  the  various  diuretics  taken  in  the  food  reacts  in  putting 
out  the  varying  amounts  of  salt. 

Dr.  O'Hara  likewise  describes    another   test   known    as   The 

"  Carried  out  by  Dr.  Henry  Christian  and  described  by  James  O'Hara  in  the 
"Archives  of  Internal  Medicine,"  Vol,  XVII. 


ACUTE  AND    CHRONIC   NEPHRITIS  319 

Added  Urea  and  Salt  Test,  which  was  first  described  by  Von 
Monakow  and  also  carried  out  in  the  Peter  Bent  Brigham  Hospital. 
The  method  used  was  as  follows : 

ADDED   UREA  AND  SALT  TEST 

Patient  is  given  75  grams  of  protein,  4  grams  of  sodium  chloride, 
and  1500  c.c.  of  water,  with  a  caloric  value  of  from  2000  to  2200 
calories.  After  the  output  of  fluid,  salt  and  nitrogen  reaches  an 
equilibrium  on  this  diet  on  one  day  10  grams  of  additional  salt  is 
given  and  several  days  later  the  patient  receives  20  grams  of  urea. 
This  order  may  be  reversed.  The  daily  output  of  urine,  salt,  and 
nitrogen  is  determined  and  charted.  After  the  salt  and  nitrogen 
is  added  to  the  diet  in  normal  individuals,  their  excretion  after 
forty-eight  hours  returns  to  its  previous  level.  In  diseased  kidney 
this  may  not  be  the  case. 

Value  of  Tests.  —  Thus  it  is  seen  that  in  these  tests  for  kidney 
functions,  an  effort  is  made  to  determine  the  extent  of  damage 
wrought  by  the  disease  upon  the  renal  organs  and  the  manner  in 
which  they  react  under  definite  circumstances.  However,  it  is 
not  so  simple  as  it  would  seem  to  formulate  a  dietary  based  on 
the  findings  resulting  from  the  renal  tests.  Notwithstanding  this, 
these  tests  are  coming  more  and  more  into  use,  both  in  hospitals 
and  private  practice,  and  a  nurse  must  understand  just  how  they 
are  carried  out,  and  must  realize  that  unless  her  part  is  per- 
formed with  absolute  accuracy  the  entire  value  of  the  test  will  be 
obliterated.  Too  much  stress  cannot  be  laid  upon  this  phase  of 
the  test,  if  it  is  to  be  of  any  value  whatsoever  in  determining  the 
condition  of  a  diseased  kidney. 

CHRONIC  INTERSTITIAL  NEPHRITIS 

This  form  of  nephiitis  is  more  insidious  in  character,  developing 
more  slowly  and  manifesting  different  characteristics,  than  those 
seen  in  some  of  the  other  types  already  mentioned.  The  condi- 
tion is,  as  a  rule,  associated  with  heart  symptoms  and  high  blood 
pressure.     The  blood  shows  an  increase  in  urea  and  other  end- 


320  DIETETICS  FOR  NURSES 

products  of  protein  metabolism,  whereas  there  is  no  manifest 
change  in  the  metaboHsm  of  salt  or  water.  The  great  increase  in 
volume  of  urine  voided  would  show  an  inability  on  the  part  of 
the  kidneys  to  eliminate  a  highly  concentrated  urine.  This 
hypothesis  is  further  demonstrated  in  the  urine  tests. 

Urinalysis.  —  Upon  analysis  the  urine  in  these  cases  shows  less 
albumen  and  fewer  casts  than  found  in  other  types  of  nephritis. 
The  disease  is  manifested  by  slight  headache,  gastric  disturbances, 
and  a  frequent  desire  to  urinate. 

Dietetic  Treatment.  —  The  treatment  here  depends  upon  the 
extent  of  the  impairment  of  the  functions  of  the  kidney.  If  the 
damage  is  not  extensive  and  the  diagnosis  has  been  sufficiently 
early  to  insure  prompt  improvement  upon  treatment,  the  diet  is 
so  directed  as  to  prevent  the  occurrence  of  any  of  the  acute  symp- 
toms. The  patient  is  warned  against  over-eating  and  drinking, 
over-exercise,  and  nervous  excitement.  When  it  is  possible,  a 
change  to  a  warm,  dry  climate  is  advisable  with  more  rest  and  sleep 
and  less  work  and  worry.  He  is  advised  to  eat  less  at  meals  and 
if  hungry  to  eat  a  light  lunch  of  milk  or  buttermilk  with  crackers 
in  the  mid-morning.  The  same  dietary  precautions  must  be  taken 
in  these  disturbances  as  in  other  nephritic  conditions,  keeping 
always  in  mind  the  fact  that  the  kidneys  are  the  chief  organs  of 
excretion  in  the  body,  and  through  them  must  pass  the  majority 
of  all  end-products  of  nitrogen  metabolism. 

Limiting  the  Nitrogen.  —  The  nitrogenous  foods  cannot  be 
eliminated  entirely,  especially  if,  as  is  often  the  case,  the  individual 
suffers  from  chronic  nephritis  and  is  up  and  about  attending  to 
business ;  but  they  can  be  judiciously  regulated  in  the  diet.  All 
such  foods  as  fried  foods,  rich  pastries,  rich  sauces  and  gravy, 
spices  of  all  kinds,  tea  and  coffee,  celery  and  asparagus,  must  be 
avoided. 

Limiting  the  Fluids.  —  Von  Noorden  limits  the  amount  of  fluid 
to  li  liters  per  day.  This  does  not  include  the  water  content  of 
the  various  foodstuffs.  He  advises  a  period  of  observation  to 
determine  the  amount  best  suited  to  the  condition  of  the  patient 
and  reducing  this  amount  from  250  to  150  c.c.  a  day  until  the 


ACUTE  AND   CHRONIC  NEPHRITIS  321 

desired  quantity  is  reached.  He  advises  a  drinking  day  once  a 
week,  allowing  the  patient  to  drink  as  much  water  as  he  likes. 

Development  of  Uremia.  —  Whenever  evidences  of  uremia 
appear  the  treatment  must  be  changed  to  meet  the  condition.  It 
is  necessarily  more  strenuous  than  that  used  ordinarily  in  the 
chronic  nephritis.  If  the  uremia  becomes  positive,  then  the  treat- 
ment laid  down  for  acute  nephritis  already  described  must  be  at 
once  instituted.  The  patient  must  be  put  to  bed  at  once  and  every 
effort  made  to  assist  the  body  in  getting  rid  of  the  causes. 

In  certain  cases  of  nephritis,  in  which  uremic  poisoning  is  due 
to  the  retention  of  the  end-products  of  nitrogen  metabolism,  or 
to  the  toxins  formed  as  a  result  of  the  tissue  changes  due  to  the 
disease,  the  water  then  instead  of  being  restricted  in  the  dietary 
is  greatly  increased  to  encourage  a  free  diuresis  with  a  consequent 
washing  out  of  the  accumulated  poison.  Certain  authorities 
recommend  a  strict  milk  and  water  diet,  as  has  already  been 
described  in  the  beginning  of  the  chapter.  A  light  or  soft  diet  is 
advised  until  the  condition  improves,  resting  the  renal  organs  as 
far  as  possible.  This  diet  may  consist  of  fruit  juices,  strained 
cereals  with  cream,  cocoa,  milk,  buttermilk,  toast,  butter,  strained 
apple  sauce,  cream  soups,  except  those  made  with  beans  or  peas. 
The  above  diet  is  gradually  increased  by  adding  a  mashed  or 
baked  potato,  well-cooked  green  vegetables,  stewed  or  raw  fruit, 
rice  and  tapioca  pudding,  and  chocolate  blancmange. 

Selection  and  Preparation  of  Food.  —  The  preparation  of  foods 
for  the  nephritic  differs  in  certain  particulars  from  that  used  in 
other  pathological  conditions,  namely,  the  restriction  of  certain 
food  constituents ;  dishes  made  with  meat  and  eggs  are  cut  out  of 
the  diet,  and  salt  is  used  as  sparingly  as  possible,  when  it  is  used 
at  all.  The  nurse  must  weigh  or  measure  out  the  maximum 
quantity  allowed  and  divide  this  in  portions  for  each  feeding, 
measuring  carefully  any  that  is  not  used  and  charting  it.  In 
this  way  it  is  possible  to  increase  or  decrease  the  amount  accord- 
ing to  the  symptoms  of  the  individual.  The  water  content  of  the 
various  foods  comprising  the  diet  is,  as  a  rule,  not  considered,  but 
it  is  necessary  to  adhere  strictly  to  the  orders  of  the  physician 


322  DIETETICS  FOR  NURSES 

and  to  curtail  the  beverages,  water,  tea,  coffee,  etc.,  until  the 
amount  conforms  to  that  laid  down  in  the  dietary. 

The  nitrogenous  foods,  with  the  exception  of  milk,  are  as  a  rule 
eliminated  from  the  nephritic  diet.  The  nurse  must  study  the 
tables  and  learn  which  food  materials  come  under  this  head.  It 
may  seem  difficult  to  prepare  diet  for  the  sick  without  eggs,  but 
it  is  possible  and  at  times  obligatory. 

Combating  Anemia.  —  In  chronic  (ambulatory)  nephritis  the 
anemia  must  be  reckoned  with.  It  is  not  safe  to  upset  the  nitrogen 
equilibrium  of  the  body,  but  it  has  been  proved  that  this  may  be 
maintained  on  as  little  as  30  or  40  grams  of  protein  a  day.  This 
will  be  seen  not  to  be  difficult  to  obtain  when  milk  forms  an  im- 
portant part  of  the  diet.  The  wheat  and  oat  cereals,  as  well  as 
the  bread,  contain  protein,  and  a  judicious  use  of  these  foods 
will  enable  the  nurse  to  give  her  patient  the  necessary  quantity 
to  offset,  in  a  measure,  the  anemia  which  is  at  times  most 
troublesome. 

Advice  to  Patient.  —  One  important  point  must  be  observed  by 
the  nurse  and  impressed  upon  the  patient  when  he  leaves  her  care. 
This  is  moderation  in  the  amount  of  food  eaten.  The  kidneys 
must  never  be  overtaxed,  even  with  foods  which  in  themselves 
seem  harmless.  As  danger  lies  in  over-indulgence,  this  point  can- 
not be  too  strongly  emphasized. 

Advice  to  the  Nurse.  —  The  use  of  the  formulas  included  in  this 
text  is  left  to  the  discretion  of  the  nurse.  In  those  calling  for 
seasoning,  such  as  pepper,  mustard,  etc.,  the  condiments  must  be 
omitted.  A  small  amount  of  celery  salt  may  be  substituted  in 
certain  instances  if  the  dish  is  unpalatable  without  something  of 
the  kind.  In  cases  where  the  salt  is  restricted  the  dishes  are  pre- 
pared as  directed,  with  the  exception  of  the  salt.  The  recipes  call- 
ing for  eggs  and  meat  are  not  to  be  used  unless  directed  by  the 
physician.  Cornstarch,  sago,  and  tapioca  may  be  used  instead  of 
gelatine.  The  following  menus  may  be  used  as  guides  in  selecting 
foods  to  prepare  for  the  nephritic  patient  after  the  rigid  regime  is 
to  a  certain  extent  relaxed : 


ACUTE  AND  CHRONIC  NEPHRITIS  323 

full  nephritic  diet  (nitrogenous  foods  restricted) 

Breakfast 

Grapefruit,  orange,  prunes,  pears,  peaches,  or  strawberries. 
Cereals  :  cream  of  wheat,  farina,  Pettijohn^s,  Ralston's,  hominy, 
grits,  and  oatmeal  with  cream. 
Toast,  buttered  or  creamed. 
Cocoa,  tea,  or  coffee,  as  directed  by  the  physician. 

Dinner 

Milk  or  cream  soup,  well-cooked  green  vegetables  with  butter 
or  cream  sauce. 

Potatoes,  white  or  sweet,  baked,  mashed,  or  boiled,  with  butter, 
bread  or  rolls. 

Stewed  tomatoes,  rice. 

Salads :  lettuce,  tomato,  romaine,  chicory,  or  fruit  salad,  with 
a  dressing  of  oil  and  lemon,  or  cream  and  lemon. 

Simple  desserts :  junkets,  cornstarch,  sago,  or  tapioca  pudding, 
baked  bananas,  rice  pudding,  apple  tapioca,  and  orange  tapioca, 
ice  cream. 

Beverages :  cocoa  or  tea,  as  directed  by  the  physician. 

Supper 

Cereals  and  cream. 

Baked  or  escalloped  potatoes. 

Baked  or  stewed  apples. 

Salads,  excepting  those  made  with  meat  or  eggs. 

Junket,  raw  or  stewed  fruit. 

Toast  or  rolls  with  butter. 

Cocoa. 

Meat,  fish  or  poultry  once  a  day.^^ 

*8  The  outside  parts  of  roast  meat  must  be  avoided,  even  when  meat  is  allowed 
once  a  day.     Meat  is  only  added  after  the  condition  materially  improves. 


324  DIETETICS  FOR  NURSES 

Breakfast 
Stewed  or  fresh  fruit. 
Cereals  with  cream. 
Toast  with  butter. 
Cocoa,  milk,  or  tea. 

Dinner 

Cream  soups. 

Boiled  chicken  or  fish. 

Potatoes,  white  or  sweet. 

Green  vegetables. 

Salads,  except  with  meat  or  eggs. 

Simple  desserts. 

Rolls  or  bread  and  butter. 

Milk  or  buttermilk. 

Supper 

Cereals  or  rice  with  cream  or  butter. 

Baked  or  escalloped  potatoes. 

Stewed  or  escalloped  carrots. 

Salads,  except  those  made  with  meat  or  eggs. 

Fresh  or  canned  pears,  cherries,  or  pineapple. . 

Bread  pudding,  junkets,  or  cornstarch  blancmange. 

Bread,  rolls,  or  toast,  with  butter. 

Cocoa,  milk,  tea,  or  buttermilk. 

TABLE   XXI 

SALT   CONTENT   OF   FOOD^^ 

According  to  Leva 

Per  Cent  of  Sodium  Per  Cent  of  Sodium 

Chloride  in  Chloride  in 

Raw  Material  Raw  Material 

Meats  Smoked  and  Salted  Foods 

Mutton 0.17  Ham  (raw)     ....  4.15-5.86 

Veal 0.13  Ham  (boiled)      .     .     .  1.85-5.35 

Calf's  brains 0.20  Salmon  (smoked)    .     .     .       7.50 

18  Coleman,  in  Forchheimer's  '*  Therapeusis  of  Internal  Diseases,"  Vol.  I,  p.  642. 


ACUTE  AND  CHRONIC  NEPHRITIS 


325 


TABLE    XXI  — Continued 

Per  Cent  of  Sodium 

Chloride  in 

Raw  Material 


Meats 

Calf's  kidney 0.32 

Calf's  liver 0.14 

Beef  (lean) 0.11 

Pork  (lean) 0.10 

Fish 

Trout 0.12 

Halibut 0.30 

Herring 0.27 

Cod 0.16 

Carp 0.086 

Salmon 0.061 

Mackerel 0.28 

Haddock 0.39 

Poultry 

Duck 0.14 

Goose 0.20 

Chicken 0.14 

Pigeon 0.15 

Turkey 0.17 

Venison 0.11 

Oysters  (washed)      .     .     .  0.52 

Oysters  (with  sea  water)   .  1.14 

Prepared  Foods 

Plasmon 0.21 

Roborat 0.0051 

Sanatogen 0.42 

Somatose 0.66 

Bovril's  preparations   0.26-14.1 
Valentine's  meat  juice    0.08-1.20 

Egg  (white  and  yolk)    .     .  0.21 

Egg  (white  alone)     .     .     .  0.21 

Egg  (yolk  alone)       .     .     .  0.039 

Caviar 3.00 

Milk  (whole) 0.16 

Cream 0.13 

Buttermilk 0.16 

Whey 0.11-0.15 

Condensed  milk  ....  0.40 
Butter  (unsalted)  .  0.02-0.21 
Butter  (salted)     .     .      1.00-3.00 

Peanut  butter      ....  4.10 

Oleomargarine      .     .     .     .  2.15 

Palmin 0.0016 

Fruetin 0.10 


Per  Cent  of  Sodium 

Chloride  in 

Raw  Material 

Smoked  and  Salted  Foods 
Bacon  (smoked)  (German)       1.01 
Bacon  (smoked)  (American)  11.61 
Corned  beef  (Qerman)     .       2.04 

Corned  beef  (American)  .  11.52 

Cod  (salt)* 23.50 

Cod  (salt,  boneless)*  .     .  19.00 

Herring  (smoked)   .     .     .  11.70 

Mackerel  (salt  dressed)    .  10.40 

Salmon  (salted,  smoked) .  10.37 
Sardines  (French  in  oil)   .       1.34 

Cod-liver  oil 0.17 

Gelatine  (dry)    ....  0.75 

Beef  marrow      ....  0.11 

Sausages  (Frankfurters)  .  2.20 
Sausages  (various kinds)  2.90-8.10 
Anchovy  paste  (Cross   & 

BlackweU's)    ....  40.1 
Meat  Extracts 

Liebig's 2.60 

Kemmerich's  ....  1.40 
Various  bouillon  capsules, 

extracts,  etc.  .     .      9.40-22.0 
Foods  Prepared  for  Table 

Bouillon 0.5-1.0 

Thick  soups  .     .     .     .     .  0.54 

Roast  beef 0.98 

Roast  pork    .     .     .     .     .  1.54 

Chops 0.97 

Roast  chicken    ....  0.39 

Sauces 0.7-1.5 

Spinach 0.91 

Cauliflower 0.49 

Stewed  pears      ....  0.019 

Macaroni  (S,  la  Napolitaine)  1.04 

Scrambled  eggs  (salted)   .  1.10 

Carrots 0.46 

Apple  sauce 0.41 

Tapioca     pudding      (un- 
salted)          0.026 

Rice,  with  apples    ...  0.18 
Cheese 

Parmesan 1.93 

Swiss 2.00 

American  (pale)      .     .     .  0.82 


*  Analysis  marked  thus  :  *  from  Atwater  &  Bryant. 


326 


DIETETICS  FOR  NURSES 


TABLE    XXI— Continued 


Per  Cent  of  Sodium 

Chloride  in 

Raw  Material 

Cheese 
Pineapple  cheese     ...       2.13 

Edam 3.30 

English  cream  cheese     0.70-1.15 

Vegetables 
Potatoes      .     .     .   '.    0.016-0.078 

Beets 0.053 

Beans 0.09 

Peas        0.058 

Lentils 0.13-0.19 

Lentils  (dried)      .     .     .     .     0.155 

Artichokes 0.036 

Cauliflower  ,  .  .  0.05-0.15 
Cucumber  (fresh)  .  0.06-0.08 
Horseradish    .     .     .      0.02-0.06 

Radish 0.075 

Celery,  stalks       .     .      0.25-0.49 

Celery,  roots 0.089 

Asparagus  ....      0.04-0.06 

Spinach 0.084-0.21 

Tomatoes 0.094 

Cabbage  ....  0.11-0.44 
Onions 0.016-0.09 

Canned  Vegetables 

Green  corn  * 0.40 

Green  peas  * 0.70 

Tomatoes 0.10 

Mushrooms     .     .     .      0.04-0.06 

Fruits 
Pineapple   .;....    0.071 

Orange 0.057-0.055 

Apricot 0.0047 

Lemon 0.0045 

Strawberry      .     .     .    0.010-0.020 
Chestnuts  ....    0.045-0.010 

Cherry         0.013 

Coconut  juice       ....     0.035 

Ohves 0.008-0.210 

Plums 0.0046 

Gooseberry 0.021 

Watermelon  juice     .     .     .     0.011 

Grape 0.024 

Almonds,  dry       ....     0.010    . 

Walnuts,  dry 0.019 

Cane  sugar 0.110 

Lump  sugar 0.049 

Chocolate  (Lindt)     .     .     .     0.073 

*  Analysis  marked  thus  :  * 


Per  Cent  of  Sodium 

Chloride  in 

Raw  Material 

Infant  Foods 
Nestle's  Food     ....       0.29 

Rademan's 0.03 

Robinson's  patent  groats      Trace 

Bread,  etc. 
Graham  bread    ....       0.61 
Pumpernickel     ....       0.46 
White  bread  ....  0.18-0.20 

Zwieback 0.38 

Macaroni 0.067 

Cereals,  etc. 

Barley 0.037 

Oats 0.046 

Rye 0.014 

Wheat 0.013 

Rice 0.039 

Corn  (maize)      ....       0.019 
Wheat  flour  .     .     .      0.002-0.008 
Oatmeal  (American)    .     .       0.29 
Oatmeal  (German)      .     .       0.28 

Quaker  oats 0.082 

0.19 


2.10 


Spices 
Capers  (preserved  in  salt) 
Capers  (preserved  in  vin- 
egar)        0.20 

Pepper,  black     ....  0.51 

Pepper,  white     ....  0.019 

Mustard 2.66 

VaniUa 0.055 

Cinnamon 0.061 

Cocoa  beans  ....  0.05-0.095 

Coffee,  roasted  ....  0.045 

Tea 0.15 

Drinks 
Ground  water    .     .    0.0012-0.0060 
Spring  water      .     .  0.00055-0.0046 

Ale        0.0017 

Beer,  German    ....  0.016 

Beer,  English      ....  0.10 
Champagne      (Moet      & 

Chandon)        ....  0.0045 

Apollinaris 0.043 

Fachinger 0.039 

Giesshuble  (Mattoni)       .  0.0021 

Vichy 0.053 

from  Atwater  and  Bryant. 


ACUTE  AND  CHRONIC  NEPHRITIS  327 

SUMMARY 

The  Kidneys  find  difficulty  in  eliminating  certain  substances, 
namely,  the  end-products  of  protein  metabolism  —  urea,  water, 
salts,  and  pur  in  bodies. 

The  Urine  constitutes  the  chief  point  of  investigation.  Anal- 
ysis shows  the  presence  of  albumen,  casts,  blood  cells,  and  pig- 
ments, with  a  corresponding  deficiency  in  the  normal  constituents, 
water,  urea,  and  salts. 

Volume  of  Urine.  —  The  volume  of  urine  is  reduced,  and  at 
times  suppressed,  owing  to  the  difficulty  with  which  the  kidneys 
eliminate  water  in  nephritic  conditions. 

The  Blood  shows  the  presence  of  the  toxic  substances  on 
account  of  the  inability  of  the  kidneys  to  eliminate  them 
properly. 

Edema  is  a  common  symptom  and  is  probably  due  to  the  re- 
tention of  salts  and  water  by  the  tissues  of  the  body.  It  is  treated 
and  at  times  relieved  by  limiting  the  intake  of  fluids  and  reducing 
the  amount  of  sodium  chloride  in  the  diet. 

Uremia  is  the  most  dreaded  symptom  and  develops  as  a  re- 
sult of  the  retained  toxins  in  the  blood.  Its  development  is  pre- 
vented, if  possible,  by  reducing  the  amount  of  fluid  and  food, 
even  of  milk,  in  the  diet. 

Uremic  Poisoning  is  an  acute  intoxication  due  to  the  ab- 
normal retention  of  these  poisons  and  the  inability  of  the  kidneys 
to  eliminate  them.  It  is  combated  by  instituting  a  starvation 
treatment  which  is  followed  by  the  above-mentioned  restricted 
diet. 

Gastro-intestinal  Disturbances,  especially  diarrhea,  are  apt  to 
develop  in  chronic  nephritis.  Care  must  be  taken  to  keep  the 
meals  small  in  size,  simple  in  proportion,  and  constituted  only 
from  the  allowed  foods. 

Anemia  follows  the  acute  attack  and  is  especially  noticeable 
in  those  cases  in  which  a  rigid  starvation  regime  has  been  found 
necessary.  It  may  likewise  be  the  result  of  a  long-continued  diet 
in  which  the  proteins  have  been  reduced  to  the  lowest  possible 


328  DIETETICS  FOR  NURSES 

amount.  The  simple  proteins  in  the  diet  must,  at  times,  be  in- 
creased and  the  patient  advised  to  take  plenty  of  fresh  air  and  sun- 
shine, in  order  to  overcome  this  progressive  anemia. 

Restrictions  in  the  diet  are  essential.  These  consist  of  limit- 
ing the  amount  of  food  and  fluids  as  well  as  the  type  of  food 
ingested. 

Restricting  the  Proteins.  —  Proteins  are  restricted  on  account 
of  the  difficulty  with  which  the  end-products  are  eliminated  by 
the  kidneys,  also  on  account  of  the  toxic  character  of  these 
substances. 

Restricting  the  Fluids.  —  It  is  necessary,  on  account  of  their 
difiiculty  of  elimination  and  because  they  impose  an  excessive  tax 
upon  the  circulatory  organs. 

Treatment  is  largely  dietetic  in  character  by  reason  of  the 
advantages  just  mentioned. 

Starvation  Treatment  is  instituted  in  order  that  the  work 
of  the  kidneys  may  be  lessened.  This  treatment  consists  of 
abstinence  from  food  with  a  definite  reduction  in  the  fluid 
intake.  It  is  found  to  be  necessary  during  the  acute  stage  of  the 
disease. 

Extreme  Thirst,  which  is  apt  to  be  an  annoying  symptom  at 
this  time,  is  relieved,  as  far  as  possible,  with  small  sips  of  water 
or  ice  pellets  held  in  the  mouth. 

Nephritic  Cures  are. devised,  as  far  as  possible,  to  relieve 
the  acute  symptoms  and  to  prevent  the  disease  from  developing 
into  a  chronic  condition.  Milk  is  the  basis  of  most  of  these  cures. 
It  is  given  in  definite  amounts  at  stated  intervals ;  the  quantity 
and  frequency  with  which  it  is  given  being  adjusted  to  the  state 
of  the  disease  and  the  condition  of  the  patient. 

The  Karell  Cure  is  one  of  the  best  known  diet  cures  used  in 
the  relief  of  acute  nephritis.  It  consists  of  the  giving  of  skimmed 
milk  three  or  four  times  a  day  in  doses  ranging  from  three  to  six 
ounces  for  one  week,  at  the  end  of  which  time,  provided  the  stools 
remain  solid,  an  increase  to  two  quarts  a  day  is  made. 

Constipation  under  the  circumstances  is  a  favorable  symp- 
tom, indicating  as  it  does  the  agreement  of  the  milk. 


ACUTE  AND  CHRONIC  NEPHRITIS  329 

Diarrhea  as  a  result  of  gastro-intestinal  disturbances  has 
directly  the  opposite  indication.  In  these  cases  the  milk  must  be 
reduced.  Karell  advises  the  boiling  of  milk  and  relieving  the  con- 
stipation by  means  of  mild  laxatives  or  enemas. 

Duration  of  the  Karell  Cure  is  from  four  to  six  weeks,  after 
which  a  gradual  return  to  a  normal  diet  is  made. 

Hunger  is  apt  to  be  prominent  at  this  stage  of  the  treatment 
and  is  relieved  during  the  second  or  third  week  by  giving  a  small 
piece  of  dry  bread  and  milk,  soup  thickened  with  a  cereal,  once 
a  day. 

Functional  Kidney  Tests  are  made  to  determine  the  char- 
acter and  extent  of  the  impairment  of  the  functions  of  the  kidneys. 
The  diets  used  in  these  tests  contain  definite  amounts  of  certain 
diuretic  substances,  and  the  analysis  of  the  urine  voided  during 
the  twenty-four  hour  period  required  by  the  test  shows  the  nature 
of  the  impairment  and  furnishes,  in  a  measure,  a  means  of  deter- 
mining the  amount  of  food  and  fluid  which  is  safe  for  the  patient 
to  take.  It  likewise  shows  the  extent  to  which  the  restrictions  in 
the  salt  and  proteins  are  necessary. 

Salt-free,  or  Salt-poor  Diets  are  necessary  in  some  cases. 
While  restriction  in  the  amount  of  salt  used  in  the  preparation  of 
food  for  the  nephritic  patient  is  always  advisable,  if  there  is  a 
tendency  to  edema,  the  salt-shaker  should  be  left  off  the  tray,  and 
when  there  is  a  definite  amount  of  salt  prescribed,  it  should  be 
weighed  or  measured  for  the  day  rather  than  for  the  meal,  and  the 
amount  consumed  recorded  after  each  feeding. 

Special  Points  for  the  nurse  to  remember  are  the  necessity 
for  an  early  recognition  of  unfavorable  symptoms  —  of  instructing 
the  patient  upon  leaving  her  care  in  the  need  for  keeping  the  size 
of  the  meals  small ;  —  of  the  danger  of  indulging  in  alcoholic  or 
other  stimulating  beverages ;  —  of  eating  highly  spiced  foods,  or 
of  eating  anything  which  may  cause  gastro-intestinal  disorders. 

She  should  emphasize  the  need  for  regular  examination  of  the 
urine  and  the  value  of  rest  and  freedom  from  nervous  excite- 
ment, and  the  need  of  living  in  the  sunshine  as  much  as 
possible. 


330  DIETETICS  FOR  NURSES 

The  nurse  should  study  the  diet  hst  and  become  familiar  with 
the  foods  allowed  and  those  to  be  avoided.  The  tables  show  the 
foods  which  are  rich  in  salts  and  proteins.  She  should  likewise 
understand  and  be  able  to  make  the  simple  test  for  albumen  in  the 
urine  and  the  method  of  collecting  the  urine  for  the  test  made  in 
the  laboratory. 


CHAPTER  XXI 
DISEASES  OF  THE  HEART 

The  dietetic  treatment  in  diseases  of  the  heart  has  been  the  sub- 
ject of  much  study,  especially  during  the  past  few  years. 

The  t>iet  —  In  this  pathological  condition,  as  in  many  other 
diseases  in  which  one  or  more  of  the  functions  of  the  body  have 
become  impaired,  there  can  be  no  hard  and  fast  rule  covering  the 
treatment  or  diet  for  all  cases,  but,  as  in  nephritis,  the  condition 
of  the  individual,  his  symptoms,  and  the  progress  and  extent  of 
the  disease  must  be  taken  into  consideration  in  order  to  formulate  a 
diet  calculated  to  adequately  nourish  the  body,  while  at  the  same 
time  imposing  the  smallest  amount  of  work  with  the  least  expen- 
diture of  labor  upon  the  part  of  the  diseased  organ. 

Division  of  Treatment.  —  The  treatment  of  the  disease  then 
may  be  said  to  be  divided  into  three  stages :  first,  the  stage  of 
compensation;  second,  that  of  moderate  compensation;  third, 
that  of  decompensation.  The  diet  is  directed,  first,  toward  re- 
lieving as  far  as  possible  the  strain  which  is  imposed  more  or  less 
by  all  the  food  eaten;  and  second,  at  keeping  up  the  general 
nutrition  of  the  body. 

Dietetic  Treatment.  —  No  matter  what  has  caused  the  impair- 
ment of  the  heart  functions,  the  treatment  must  necessarily  remain 
the  same  as  far  as  diet  i§  concerned.  The  patient  is  no  longer  able 
to  handle  a  full  and  unrestricted  diet.  As  long  as  compensation 
is  good,  the  restrictions  are  scarcely  noticeable ;  alcoholic  beverages 
and  possibly  tobacco  may  have  to  be,  to  a  certain  extent,  curtailed, 
and  in  some  cases  avoided  altogether.  However,  if  the  individual 
desires  to  live  and  be  comfortable  while  so  doing,  he  must  lead  a 
wholesome,  simple  life,  since  he  cannot  with  safety  indulge  in  any 
excesses,  either  in  diet  or  in  any  other  particular. 

331 


332  DIETETICS  FOR  NURSES 

Diet  in  Second  Stage.  —  When  the  second  stage  sets  in,  that  is, 
when  the  heart  muscle  is  unable  to  perform  its  normal  function, 
attention  must  be  directed  toward  two  main  points;  first,  the 
work  of  the  heart;  second,  the  pressure  upon  that  organ  from 
other  sources,  namely,  the  stomach  and  intestines.  As  long  as 
the  food  does  not  disagree,  that  is,  so  long  as  there  is  no  fermenta- 
tion or  putrefaction  of  the  food  material  in  the  stomach  and  in- 
testines the  flatulence  arising  from  the  evolution  of  gas  in  those 
organs  is  slight  and  the  pressure  upward  upon  the  heart  incon- 
siderable. 

Restricting  the  Fluids.  —  The  heart  must  be  spared  all  unneces- 
sary work.  This  can  only  be  accomplished  by  limiting  the 
amount  of  food  and  fluids  ingested.  The  latter  imposes  an  extra 
burden  upon  the  impaired  organ  to  eliminate.  Consequently,  the 
amount  of  fluid  should  be  limited  to  1500  c.c.  a  day  at  most, 
and  in  many  cases  considerably  less  than  that  quantity. 

Regulating  the  Meals.  —  The  meals  should  be  small  and  the  in- 
tervals of  feeding  regular.  It  has  been  found  best  to  give  the 
fluids  between  meals  rather  than  with  the  food.  In  many  cases 
of  heart  disease,  as  in  certain  nephritic  conditions,  edema  is  a 
prominent  symptom,  so  that  it  is  necessary  to  direct  our  efforts 
toward  overcoming  that  particular  condition.  The  Karell  Cure  ^ 
and  the  salt-poor  diet  are  used  with  excellent  results.  The  latter 
is  not  so  low  as  the  former,  and  in  many  cases  will  accomplish  all 
that  is  required.  A  modified  Karell  diet  is  used  in  the  Michael 
Reese  Hospital  ^  in  Chicago  as  follows  : 


(Salt  free) 

"  Milk  200  c.c.  at  8  a.m.,  12  m.,  4  p.m.,  and  8  p.m.,  for  five  to 
seven  days. 
Eighth  day  —  Milk  same  as  above. 

10  A.M.  one  soft  egg ;  6  p.m.  2  slices  of  dry  toast. 

1  See  Karell  Cure,  p.  310. 

2  "Food  for  the  Sick,"  p.  150,  by  Strouse  and  Perry. 


DISEASES  OF  THE  HEART  333 

Ninth  day  —  Milk  as  above. 

10  A.M.  one  soft  egg  and  2  slices  of  toast. 

Tenth  to  twelfth  day  —  Milk  as  above. 

12  M.  chopped   meat,    rice  boiled   in  milk,    easily   digested 
vegetables. 

6  P.M.  one  soft-boiled  egg. 

The  diet  is  gradually  increased  until  a  full  tray  is  reached.  All 
meats  and  vegetables  should  be  -chopped  or  scraped  at  first,  and 
the  heavier  foods  should  be  given  only  when  the  heart  is  prac- 
tically compensated.'* 

Rules  and  Regulations.  —  There  are  a  few  general  rules  which 
it  has  been  found  advisable  to  impress  upon  individuals  suffering 
from  a  disease  in  which  the  muscles  of  the  heart  have  become 
weakened.  The  compensation  of  the  organ  may  improve,  but 
there  is  still  a  danger  of  a  re-occurrence  or  a  further  development 
more  or  less  serious,  and  at  times  fatal.  So  for  this  reason,  cer- 
tain rules  must  be  observed  throughout  life : 

First :  the  necessity  for  keeping  the  meals  small,  simple,  and 
digestible.  Death  at  times  occurs  with  symptoms  of  gastric  dis- 
turbance, which  is,  after  all,  due  to  the  heart.  Consequently  it 
is  not  wise  to  invite  such  disaster  by  overeating,  or  by  the  par- 
taking of  any  food  which  is  liable  to  bring  about  indigestion, 
either  in  the  stomach  or  in  the  intestines.  Most  authorities  advise 
four  or  five  meals  a  day  rather  than  the  regulation  three,  and  limit 
the  fluids  at  meal  time  to  a  few  ounces  only,  when  any  are  allowed, 
and  to  a  maximum  amount  of  1500  c.c.  during  the  day,  chiefly 
between  meals. 

Second :  the  need  for  limiting  the  amount  and  type  of  exercise 
taken,  especially  after  eating,  since  the  work  of  digestion  requires 
all  the  power  and  strain  of  which  the  heart  is  capable,  and  since 
an  additional  tax  placed  upon  it  by  muscular  exertion  might  readily 
be  just  the  final  straw,  the  added  fraction  w^hich  weighs  down  the 
balance  on  the  scale  of  life. 

•Third  :  the  advisability  of  abstaining  from  alcoholic  beverages, 
unless  specially  prescribed  by  the  physician  in  charge. 

Certain  elderly  people  suffer  from  a  condition  known  as  senile 


334  DIETETICS  FOR  NURSES 

heart,  which  is  more  or  less  associated  with  arteriosclerosis  and 
high  blood  pressure.  These  individuals  should  be  prevailed  upon 
to  take  the  precaution  of  regulating  their  habits  of  life,  avoiding 
excesses  of  all  kinds,  not  only  on  account  of  the  weakened  condi- 
tion of  the  heart,  but  also  on  account  of  the  condition  of  the  arteries. 
They  should  avoid  excitement  and  worry,  since  the  very  fact  that 
they  are  worrying  increases  the  blood  pressure.  Simple  foods  in 
limited  quantities,  five  meals  a  day  instead  of  three,  and  an  avoid- 
ance of  too  much  fluid,  should  be  the  keynote  of  their  daily 
regime. 

Tact  on  the  part  of  the  nurse  is  necessary  in  all  cases,  both 
young  and  old.  It  is  often  more  difficult  to  instill  good  dietary 
habits  in  heart  patients,  after  acute  symptoms  have  subsided, 
than  to  carry  them  out  during  the  acute  attack,  when  the  life  itself 
depends  upon  a  rigid  adherence  to  the  diet  prescribed.  But  as 
these  rules  and  regulations  are  essential  to  the  future  welfare  of 
the  patient,  he  must  be  taught  with  care,  and  in  such  a  way  that 
he  will  not  be  alarmed  to  an  extent  when  more  harm  than  good 
will  come  of  the  teaching. 

The  diet  should  consist  chiefly  of  milk,  eggs,  rare  meat  in 
moderation  (mutton,  chicken,  fish;  and  oysters),  well-baked  bread, 
well-cooked  cereals,  potatoes  and  green  vegetables,  and  simple 
desserts.  All  foods  which  in  any  way  cause  gastric  or  intestinal 
disturbances  must  be  avoided.  If  these  disturbances  arise  during 
the  course  of  the  disease,  the  patient  should  be  promptly  returned 
to  the  strict  milk  diet.  When  edema  is  prominent,  it  is  treated  as 
already  described  in  the  treatment  for  the  like  condition  in  nephri- 
tis by  the  Karell  or  salt-free  diet. 

The  dietetic  treatment  given  here  is  merely  a  guide  to  be  used 
under  certain  conditions.  The  physician  formulates  the  diet,  and 
the  nurse  must  understand  what  to  expect  and  how  to  apply  the 
treatment  as  the  symptoms  arise. 


DISEASES  OF  THE  HEART  335 


SUMMARY 


Dietetic  Treatment,  adjusted  to  relieve  the  weakened  heart 
muscles  and  to  save  the  organ  from  all  possible  strain. 

Three  Stages,  during  which  the  treatment  changes  according 
to  the  extent  and  progress  made  by  the  disease. 

First  Stage  :  The  diet  is  practically  normal.  Compensation  is 
good,  consequently  no  dietary  measures  save  the  limiting  of 
alcoholic  beverages  are  necessary. 

Second  Stage:  The  compensation  is  only  moderate  and  the 
heart  cannot  perform  its  normal  functions,  hence  the  diet  must  be 
directed  toward  relieving  any  pressure  upon  the  organs  from  other 
organs  and  toward  lessening  the  work  of  the  heart  itself. 

Third  Stage :  In  which  the  compensation  is  decidedly  im- 
paired and  for  this  reason  the  dietetic  treatment  undergoes  a 
decided  change. 

Digestional  Disturbances  in  which  there  is  an  evolution  of 
gas  in  the  stomach  or  intestines  may  cause  a  pressure  against  the 
heart  which  is  distinctly  bad  for  it. 

Limiting  the  Fluids  in  the  diet  in  heart  disease  is  necessary 
when  the  compensation  is  only  moderate,  as  they  impose  an 
extra  burden  upon  the  organ  to  eliminate  them. 

Amoimt  of  Food  must  also  be  limited.  The  meals  must  be 
small  and  taken  without  fluid.  The  latter  should  be  taken  be- 
tween meals. 

Edema  occurs  in  a  number  of  cases  and  must  be  treated  as  in 
nephritic  conditions  by  limiting  the  fluids  and  by  confining  the 
diet  to  ''  salt-poor  "  foods. ^ 

Karell  Cure  or  modification  thereof  has  been  used  with  good 
results  in  many  cases  of  heart  disease. 

Exercise  must  be  limited  in  amount  and  confined  to  types 
which  will  not  impose  a  tax  upon  the  weakened  heart  muscles. 
Exercise  after  eating  is  especially  to  be  discouraged,  as  this,  to- 
gether with  the  efforts  required  for  the  digestion  of  food,  might 
readily  prove  too  much  for  the  heart  to  accomplish. 

»  See  Salt-poor  Diets,  pp.  308-310. 


336  DIETETICS  FOR  NURSES 

Elderly  Patients  must  be  warned  against  exercises  of  all 
kinds,  not  only  on  account  of  the  condition  of  the  heart,  but  also 
on  account  of  the  condition  of  the  arterial  walls.  These  harden 
with  age  and  break  down  under  undue  pressure. 

The  Nurse  should  instruct  the  patient  on  the  points  neces- 
sary for  the  saving  of  the  heart.  She  should  teach  the  necessity 
for  keeping  the  meals  small  and  having  them  more  frequently  if 
necessary;  of  limiting  the  fluids  at  meals  to  a  few  ounces  or 
leaving  them  out  altogether  at  this  time.  She  should  know  how 
necessary  is  the  reduction  of  the  fluid.  She  should  also  warn 
against  the  taking  of  alcoholic  beverages  except  with  the  permis- 
sion and  advice  of  a  physician. 

Excitement  and  Worry  increases  the  blood  pressure,  hence 
must  be  avoided  by  individuals  suffering  with  any  form  of  heart 
disease. 


CHAPTER  XXII 
DIABETES   MELLITUS 

Definition.  —  Diabetes  is  a  disease  which  is  characterized  by 
an  inability  on  the  part  of  the  body  to  utilize  the  carbohydrates, 
in  consequence  of  which  there  is  abnormal  excretion  of  glucose  in 
the  urine. 

Sugar  in  the  Urine.  —  The  appearance  of  sugar  in  the  urine 
may  not  necessarily  signify  diabetes,  it  may  be  merely  a  temporary 
glycosuria  due  to  certain  pathological  conditions,  such  as  infectious 
diseases,  diseases  or  trauma  which  affect  the  pancreas,  and  which 
disappear  upon  the  recovery  from  the  disease.  But  any  appear- 
ance of  sugar  in  the  urine  should  be  looked  upon  with  suspicion, 
since  the  future  welfare  of  the  patient  depends  largely  upon  an 
early  diagnosis  in  any  form  of  diabetes. 

True  Diabetes.  —  Allen  claims  that  true  diabetes  may  always 
be  distinguished  from  nervous  glycosuria  by  the  application  of  the 
laws  governing  these  conditions  (Allen's  Paradoxical  Law  ^), 
which  is  "  whereas  in  normal  individuals  the  more  sugar  given  the 
more  is  utilized,  the  reverse  is  true  in  diabetes." 

Manufacture  of  Sugar  from  Other  Foods.  —  If  the  carbohydrate 
foods  alone  caused  all  the  trouble  in  diabetes,  the  disease  might 
be  more  easily  controlled.  This,  we  found,  however,  not  to  be 
true,  since  in  certain  conditions  the  body  utilizes  the  protein  foods 
for  the  manufacture  of  glucose  also.  Consequently  in  diabetes  if 
the  absolute  sugar  output  of  the  body  is  to  be  controlled,  the  in- 
take of  nitrogenous  foods  must  be  likewise  adjusted. 

Fimctions  of  Carbohydrates.  —  In  the  chapter  describing  the 
functions  of  the  carbohydrates  in  the  human  body  it  was  demon- 
strated that  their  energy-producing  properties  did  not  cover  the 

1  Allen's  Paradoxical  Law,  quoted  from  "  Treatment  of  Diabetes  Mellitus," 
p.  18,  by  Joslin. 

z  337 


338  DIETETICS  FOR  NURSES 

extent  of  their  usefulness.  It  has  been  proved  that  this  food  con- 
stituent normally  acts  as  neutralizing  agent  for  the  toxic  acids 
produced  within  the  organism  as  a  result  of  the  breaking  down  of 
the  fats.  Hence,  when  this  function  of  the  carbohydrates  becomes 
impaired,  these  acids,  Oxybutyric  acid,  Diacetic  acid  and  Acetone, 
fail  to  be  neutralized  and  are  consequently  absorbed  into  the 
blood  stream,  giving  rise  to  a  form  of  intoxication  known  as  aci- 
dosis. When  acidosis  becomes  extreme,  the  diabetic  patient  is 
apt  at  any  time  to  succumb  to  the  dreaded  diabetic  coma. 

Keeping  Urine  Sugar  Free.  —  Thus  it  is  seen  that  the  treatment 
of  diabetes  mellitus  consists  not  alone  of  freeing  the  urine  from 
sugar  and  keeping  it  free,  but  of  controlling  the  acidosis,  which 
may  at  any  time  develop. 

Diabetic  Cures.  —  Numberless  so-called  diabetic  cures  have 
been  brought  forward  and  more  or  less  tested  for  years,  but  whether 
they  have  really  accomplished  cures  has  not  been  satisfactorily 
proved.  Not  until  Dr.  Allen  instituted  what  is  known  as  the 
Allen's  Starvation  Treatment  has  the  disease  been  so  universally 
treated,  at  least  by  one  method  or  modification  of  one  method. 
Dr.  Joslin,  who  has  used  this  treatment  most  successfully,  does  not 
claim  to  have  accomplished  a  cure,  but  states  that  he  is  watching 
the  results  of  the  treatment  in  his  patients  with  interest. 

Starvation  Treatment.  —  The  Allen  Starvation  Treatment  con- 
sists of  first  a  period  of  about  forty-eight  hours  in  which  the  patient 
is  given  an  ordinary  diet,  during  which  time  the  daily  weight  is 
taken  and  the  urine  examined  and  recorded. 

Acidosis.  —  It  has  been  found  in  some  cases,  such  as  with 
elderly  patients  or  those  in  whom  there  is  an  evident  acidosis, 
advisable  to  precede  the  period  of  starvation  by  a  preliminary 
treatment. 

Method  of  Treatment.  —  Joslin  ^  suggests  the  following  method 
of  procedure : 

''  Without  otherwise  changing  the  diet  omit  fat.  After  two 
days,  omit  protein,  then  halve  the  carbohydrates  daily  until  the 
patient  is  taking  only  ten  grams,  then  fast." 

'  "Treatment  of  Diabetes  Mellitus,"  p.  305,  Joslin. 


DIABETES  MELLITUS 


339 


In  the  Michael  Reese  Hospital,  the  following  series  of  test  diets 
are  given  to  determine  the  severity  of  the  diabetes : 


DIABETIC   TEST   DIETS' 


Breakfast 


Grapefruit 
Eggs  .  . 
Bacon  .  . 
Bread    .     . 


2 

20  grains 
25  grams 


Butter 10  grams 

Cream 15  c.c. 

Coffee     ......     1  cup 


Dinner 


Cream  soup   . 
Roast  beef 
Spinach      .     . 
Kohl-rabi  . 
Lettuce  salad 
Ripe  olives     . 


Lamb  chop    .     . 
Asparagus  tips    . 
Eggplant   .     .     . 
Tomato  salad 
Custard  (diabetic) 


3  oz. 

75  grams 

100  grams 

100  grams 

50  grams 

15  grams 


Bread 25  grams 

Butter 20  grams 

Wine  gelatine  ....  4  oz. 

Coffee 

Cream 15  c.c. 


Supper 

1  Coffee 

50  grams  Cream 15  c.c. 

50  grams  Butter 20  grams 

50  grams  Bread 25  grams 


Diet  in  Mild  Cases.  —  This  diet  contains  approximately  70 
grams  of  protein,  100  grams  of  fat,  and  70  grams  of  carbohydrates, 
and  the  patient  is  kept  on  it  for  at  least  two  days ;  then  the  car- 
bohydrates are  cut  down  by  taking  away  25  grams  of  bread  every 
day. 

If  the  case  is  a  mild  one,  this  may  be  sufficient  to  free  the  urine 
from  sugar,  but  the  diet  is  given  primarily  to  enable  the  physician 
to  find  out  by  means  of  urinalysis  just  how  great  is  the  functional 
impairment. 

In  some  cases,  which  are  mild  in  character,  the  urine  is  made 
free  of  both  sugar  and  acetone  without  further  dietetic  measures. 
However,  when  a  severe  diabetes  is  manifested  and  a  high  per- 
centage of  glucose  and  in  some  cases  acetone  bodies  are  found  in 
the  urine  a  more  rigid  treatment  will  be  found  necessary. 


'  "Food  for  the  Sick,"  by  Strouse  &  Perry. 


340 


DIETETICS  FOR  NURSES 


Preliminary  Diet.  —  Many  physicians  find  it  advisable,  as  has 
already  been  stated,  to  cut  down  the  food  allowance  before  stop- 
ping it  entirely.  In  the  Michael  Reese  Hospital  this  is  done  by 
first  giving  a  practically  fat-free  diet,  followed  by  one  or  two  days 
in  which  three  or  four  eggs,  250  to  300  grams  (8  or  10  ounces)  of 
5%  vegetables  are  given,  after  which  it  is  found  safe  to  institute 
the  starvation  treatment. 

Sample  Menus.  —  The  following  menus  are  given  to  illustrate 
the  dietetic  treatment  which  it  is  deemed  advisable  to  insti- 
tute in  cases  where  the  starvation  treatment  cannot  be  given 
at  once : 

After  the  test  diet  of  forty-eight  hours,  the  following  regime  is 
instituted : 

THIRD   DAY 


Breakfast : 
1  grapefruit    . 
1  egg     .     .     . 
1  slice  bread  . 
Tea  or  coffee  . 

Protein 
Gm. 

Fat 
Gm. 

Carbohy- 
drate 
Gm. 

Calories 

.       30  gm. 

180  c.c. 

90  gm. 
100  gm. 

90  gm. 

90  gm. 

50  gm. 

100  gm. 

20  gm. 

5.3 
2.6 

4.1 
.3 

5 

15 

_ 

20 
59 
73 

Total  for  meal 

Dinner : 

Broth     .... 

7.9 

3.7 

18.2 
2.0 
1.8 

4.2 

4.4 

.17 
2.1 

.09 

20 

.34 

3.0 
15.6 

2.7 

152 

18 

Chicken  (breast) 
Spinach      .     .     . 
Potato  (1  medium) 
Lemon  jelly    .     . 

92 
20 
70 
27 

Total  for  meal     .     . 

Supper : 

Lamb  chop     .     . 
Asparagus 
Bread    .... 
Tea  or  coffee 

29.9 

9.3 
1.5 
1.6 

2.3 

14.1 
.2 

21.6 

3 
10 

227 

126 

18 
48 

Total  for  meal 
Total  for  day 

12.4 
40.2 

14.3 
21 

13 
54.6 

192 
571 

DIABETES  MELLITUS 
FOURTH   DAY 


341 


Protein 
Gm. 

Fat 
Gm. 

Carbohy- 
drate 
Gm. 

Calories 

Breakfast : 

^  grapefruit    .     .     . 

1  egg 

1  slice  bread  ...      20  gm. 
Coffee  or  tea 

5.3 
1.6 

4.1 
.2 

5 
10 

20 
59 

48 

Total  for  meal    .     . 

Dinner : 

Tomato  bouillon      .    180  gnu 
Whitefish  ....      90  gm. 
Boiled  onions      .     .    100  gm. 
Bran  muffin  (1)  .     . 
Tea  or  coffee 

6.9 

2.2 
2 

1.5 
5 

4.3 

.23 

.3 

7 

15 

2.5 

5 

7.5 

4.5 

107 

15 

28 

40 

101 

Total  for  meal     .     . 

Supper : 

1  egg 

Tomato  (baked)       .    100  gm. 
Bran  muffin  (1)  .     . 
Tea  or  coffee 

25.7 

'■I 

1 

16.2 

4.1 
5 

20.5 

2 

7 

322 

59 

10 

101 

Total  for  meal     .     . 
Total  for  day .     .     . 

6.8 
38.4 

9.1 
29.6 

9 
44 

170 
513 

FIFTH   DAY 


Breakfast : 

\  grapefruit    .     .     . 

Broiled  tomato    .     .    100  gm. 

Tea  or  coffee 

1.5 

5 
3 

20 
18 

Total  for  meal    .     . 

Dinner : 

Broth 120  c.c. 

Lettuce      ....      50  gm. 
Cauliflower     ...      90  gm. 
Tea  or  coffee 

1.5 

3 
.5 
1.5 

.4 

8 

1.5 
3.9 

38 

12 

8 

25 

Total  for  meal     .     . 

Supper : 

1  egg 

String  beans  .     .     .    100  gm. 

Celery 50  gm. 

Tea  or  coffee 

5 

5.35 
2 
.5 

.4 
4.16 

5.4 

5 
1.5 

45 

59 

28 

8 

Total  for  meal     .     . 
Total  for  day      .     . 

7.85 
14.3 

4.16 
12.5 

6.5 
19.9 

85 
168 

342 


DIETETICS  FOR  NURSES 
SIXTH   DAY 


Protein 
Gm. 

Fat 
Gm. 

Carbohy- 
drate 
Gm. 

Calories 

Breakfast : 

Asparagus  tips    .     .      60  gm. 
Spinach      ....      60  gm. 
Tea  or  coffee 

1.5 
1.1 

1.8 

3 

1.8 

18 
32 

Total  for  meal     .     . 

Dinner : 

Stewed  celery      .     .    100  gm. 
String  beans  ...      50  gm. 
Tea  or  coffee 

2.68 

1 
1.5 

1.8 
.10 

5.8 

2.1 
2.5 

50 

15 
16 

Total  for  meal     .     . 

Supper : 

Beet  tops  ....      75  gm. 
Onions  (boiled)   .     .      75  gm. 
Tea  or  coffee 

2.5 

1.5 
1.5 

.1 
.3 

5.6 

2.5 
7.5 

31 

16 
44 

Total  for  meal     .     . 
Total  for  day      .     . 

3 
11.2 

.3 
2.2 

10 
21.4 

60 
141 

FAST 

Method  of  Administering  Treatment.  —  In  many  cases  the 
patient  is  first  put  to  bed  during  the  starvation  treatment,  but 
recently  Dr.  Allen  has  emphasized  the  value  of  exercise,  claiming 
that  it  assists  in  utilizing  the  sugar.  In  any  case,  the  starvation 
regime  remains  the  same.  The  patient  is  given  only  coffee  or  clear 
broth  with  or  without  whisky  (one  ounce  every  two  hours)  and  the 
treatment  continued  from  one  to  four  days,  or  until  the  urine 
becomes  sugar  free.^ 

It  has  rarely  been  found  necessary  to  continue  the  fast  longer 
than  four  days,  since  in  most  cases  the  sugar  decreases  rapidly 
upon  the  discontinuance  of  food. 

Loss  of  Weight.  —  The  slight  loss  of  weight,  which  may  be 
noticeable  as  the  result  of  starvation,  is  not  undesirable,  especially 

*  The  giving  of  ooffee  or  clear  broth,  with  or  without  whisky,  does  not  materially 
affect  the  starvation  and  serves  to  make  the  patient  more  comfortable  during  this 
trying  period. 


DIABETES  MELLITUS  343 

in  those  cases  where  obesity  is  a  prominent  feature.  In  fact  care 
must  be  exercised  in  the  follow-up  treatment  to  prevent  the  taking 
on  of  weight  by  the  diabetic  individual,  since,  according  to  Allen, 
it  is  often  found  that  even  moderately  obese  patients  (180  lb.) 
continue  to  excrete  a  small  amount  of  sugar  so  long  as  they  hold 
this  weight,  even  upon  a  low  carbohydrate  diet,  whereas  those 
same  patients  show  no  difficulty  in  becoming  sugar  free  if  the 
weight  is  reduced  by  ten  or  fifteen  pounds. 

SCHEDULE  FOR  TREATMENT  AND  METHODS  OF  DETERMINING  FOOD 

TOLERANCES 

A  number  of  schedules  have  been  devised  to  enable  the  nurse 
successfully  to  carry  out  the  Allen  Treatment.  In  following  out 
this  treatment  and  reeducating  the  organs  afterward  to  tolerate 
foods  which  they  have  been  unable  to  handle  on  account  of  the 
impairment  of  the  sugar-making  organs,  it  is  necessary  to  make 
a  series  of  tests  whereby  the  diet  is  gradually  increased  in  its  vari- 
ous constituents  until  the  diabetic  patient  is  able  to  handle  a 
reasonable  amount  of  carbohydrates  as  well  as  other  foods  which 
have  given  more  or  less  trouble  in  the  past. 

The  following  schedule,  after  Joslin,^  is  included,  and  a  careful 
study  of  it  is  advised  in  order  that  the  nurse  may  intelligently 
carry  out  the  Allen  Treatment. 

Schedule.  —  Fasting  in  many  cases  begins  at  once  and  the  pa- 
tient experiences  no  ill  effects  from  it.  However,  in  severe,  long- 
standing cases  many  patients  do  better  if  the  fats  are  omitted  at 
once  and  the  rest  of  the  diet  left  unchanged  for  two  days.  Then 
the  proteins  in  the  diet  are  omitted  and  the  carbohydrates  cut  in 
half.  This  halving  of  the  carbohydrates  is  continued  daily  until 
only  10  grams  remain,  after  which  they  too  are  omitted.  The 
fast  is  thus  made  complete  and  remains  so  until  the  urine  is  en- 
tirely free  from  sugar. 

Carbohydrate  Tolerance  is  determined  by  giving,  as  soon  as 
the  urine  has  been  sugar-free  for  twenty-four  hours,  150  grams 

*  Dr.  Joslin  has  given  a  very  complete  schedule  in  his  "Treatment  of  Diabetes 
Mellitus,"  from  which  the  above  schedule  is  taken. 


344  DIETETICS  FOR  NURSES 

of  5%  vegetables.  This  is  equivalent  to  from  8  to  10  grams  of  car- 
bohydrates. After  this  5  grams  of  carbohydrates,  or  75  grams  of 
5%  vegetables,  are  added  daily  to  the  diet  until  the  patient  is  taking 
20  grams.  Then  the  addition  of  5  grams  of  carbohydrates  is  made 
every  other  day,  using  the  fruits  and  vegetables  belonging  to  the 
10%  and  15%  carbohydrate  group,  until  potatoes  and  oatmeal  and 
finally  bread  can  be  tolerated  unless  sugar  appears  in  the  urine 
before  this  or  the  tolerance  reaches  3-  grams  to  each  kilogram 
of  body  weight  or,  in  other  words,  until  a  man  weighing  150  pounds 
is  consuming  225  grams  of  carbohydrates  per  day. 

Protein  Tolerance.  —  In  making  the  test  for  the  protein  toler- 
ance it  is  necessary  to  wait  until  the  urine  has  been  sugar  free  for 
forty-eight  hours ;  20  grams  of  protein  is  then  given.  This  is  equiv- 
alent to  3  eggs,  and  daily  additions  of  5  grams  protein  are  made, 
usually  in  the  form  of  meat,  until  the  patient  is  receiving  1  gram 
of  protein  to  every  kilogram  of  his  body  weight  per  day  unless  his 
carbohydrate  tolerance  is  zero,  in  which  case  it  is  wise  to  add  only 
three-fourths  of  a  gram  of  protein  per  day. 

Fat  Tolerance.  —  A  determination  of  the  fat  tolerance  is  made 
coincidently  with  that  of  the  protein.  No  additional  fat  is 
allowed  until  the  protein  tolerance  reaches  1  gram  per  kilogram 
of  body  weight,  unless  the  patient's  tolerance  for  protein  is  less 
than  that.  After  which  25  grams  of  fat  per  day  are  added  until 
there  is  no  further  loss  of  weight,  taking  care  never  to  allow 
more  than  40  calories  per  kilogram  of  body  weight. 

Reappearance  of  Sugar.  —  Should  the  urine  again  show  the 
presence  of  sugar,  another  period  of  fasting  lasting  for  twenty-four 
hours,  or  until  the  urine  is  again  sugar  free,  must  be  instituted. 
After  the  second  fast  the  increase  in  the  diet  may  be  twice  as  rapid 
as  used  after  the  first  fast.  However,  it  is  not  advisable  to  in- 
crease the  amount  of  carbohydrates  to  more  than  half  of  that 
determined  by  the  former  tolerance  for  a  period  of  two  weeks, 
during  which  time  the  urine  has  been  entirely  sugar  free,  then  the 
increase  is  made  more  slowly  and  the  amount  given  should  not 
exceed  5  grams  a  week. 

Weekly  Fast  Days.  —  One  day  in  seven  should  be  set  aside  by 


DIABETES  MELLITUS  34S 

the  diabetic  patient  for  fasting,  when  the  carbohydrate  tolerance 
is  less  than  20  grams.  When,  however,  the  tolerance  is  between 
20  and  50  grams  of  carbohydrates,,  the  patient  may  take  one-half 
of  his  daily  allowance  of  protein  and  fat  and  a  certain  amount  of 
5%  vegetables  as  well  upon  the  weekly  fast  day.  When  the  toler- 
ance reaches  between  50  and  100  grams  per  day,  vegetables  of  a 
higher  carbohydrate  content  may  also  be  included.  If  the  car- 
bohydrate tolerance  should  exceed  100  grams  per  day,  the  carbo- 
hydrates upon  the  fast  day  may  be  simply  half  of  the  amount 
allowed  upon  other  days. 

The  Giving  of  Alkalies.  —  If  acidosis  is  evident,  as  may  be  indi- 
cated by  an  excretion  of  diacetic  acid,  oxybutyria  acid,  or  acetone 
in  the  urine,  alkalies  may  be  given.  Bicarbonate  of  soda  may  be 
given  in  doses  of  2  grams  every  3  hours,  as  suggested  by  Hill  and 
Eckman,^  but  this  is  not  as  a  rule  necessary,  for,  as  Jacobi  aptly 
remarks :  "  Prevention  is  the  treatment  of  acidosis  in  children, 
and  those  susceptible  to  acidosis  should  not  have  fat.''  What  he 
has  said  for  children  holds  good  for  adults.  However,  it  is  like- 
wise true  that  fat  must  constitute  a  large  part  of  a  diabetic  diet 
and  the  only  way  to  prevent  it  poisoning,  is  to  raise  the  fat  in  the 
diet  gradually  until  the  tolerance  is  determined. 

Determining  the  Extent  of  Acidosis.  —  It  will  be  remembered 
that  in  an  earlier  chapter  it  was  found  that  the  excretion  of  ammonia 
in  the  urine  to  a  certain  extent  indicated  the  extent  of  the  acidosis 
in  the  body,  that  is,  if  the  ammonia  output  exceeds  three  or  four 
grams  a  day  (twenty-four  hours),  the  extent  of  the  acidosis  is  con- 
siderable, while  if  it  falls  below  that  amount  it  is  not  alarming. 
More  exact  methods,  however,  for  the  determining  of  the  severity 
of  the  acidosis  will  be  found  in  another  part  of  this  text,  where 
the  test  for  sugar  and  the  acetone  bodies  will  be  explained  in 
detail. 

Dietetic  Treatment.  —  The  patient  is  placed  upon  a  vegetable 
diet  consisting  of  vegetables  containing  not  more  than  five  per  cent 
carbohydrate.^    These  vegetables  have  their  carbohydrate  content 

*  Hill  and  Eckman's  "Starvation  (Allen)  Treatment  of  Diabetes." 
7  See  5%  vegetable,  p.  346. 


346 


DIETETICS  FOR  NURSES 


still  further  reduced  by  changing  the  water  in  which  they  are 
cooked  three  times.  In  many  cases  this  will  reduce  their  content 
as  much  as  one-half. 

A  small  amount  of  fat  usually  in  the  form  of  butter  is  allowed 
with  these  vegetables.  The  amount  of  5%  vegetables  given  must 
be  carefully  adjusted  since  the  patient  might  readily  take  too 
much  if  allowed  to  follow  the  dictates  of  his  appetite. 

The  carbohydrate  intake  during  the  first  one  or  two  days  must 
be  limited  to  15  grams.  This  allows  about  10  grams  of  pro- 
tein, 7  grams  of  fat,  and  15  grams  of  carbohydrates.  Tea  or 
coffee,  without  sugar  or  cream,  may  be  given  at.  each  of  the 
three  meals. 

The  following  table  is  included,  showing  the  various  foods  ar- 
ranged according  to  their  carbohydrate  content : 

TABLE   XXII 8 

Strict  Diet 

Meats,  fish,  broths,  gelatine,  eggs,  butter,  olive  oil,  coffee,  tea,  and 
cracked  cocoa. 

Foods  arranged  approximately  according  to  per  cent  of  carbohydrates 


5% 

10% 

15% 

20% 

PQ  Lettuce 

Brussels  sprouts 

Pumpkin 

Greens 

Potatoes 

^  Cucumbers 

Water  cress 

Turnip 

Peas 

Shell  beans 

1  Spinach 

Sea  kale 

Kohl-rabi 

Artichokes 

Baked  beans 

^  Asparagus 

Okra 

Squash 

Parsnips 

Green  corn 

o  Rhubarb 

Cauliflower 

Beets 

Canned  lima 

Boiled  rice 

'^  Endive 

Eggplant 

Carrots 

beans 

Boiled  maca- 

v^ Marrow 

Cabbage 

Onions 

roni 

^^  Sorrel 

Radishes 

Mushrooms 

Prunes 

J  Sauerkraut 

Leeks 

^  Beet  greens 

String  beans 

1^  Dandelion 

Broccoli 

j^  Swiss  chard 
Celery 

Tomatoes 

»  Table  used  by  Dr.  Joslin  in  his  treatment  of  diabetes  mellitus.  It  is  convenient, 
and  many  changes  in  the  diet  may  be  made  by  substituting  one  food  for  another 
of  like  carbohydrate  content.  This  table  can  be  purchased  on  cards  from  Thomas 
Grooms  &  Co.,  Boston,  Mass. 


DIABETES  M^LLITUS 
TABLE  XXll  — Continued 


347 


5% 

10% 

15% 

20% 

Ripe  olives 

(20  7(,  fat) 

Lemons 

Apples 

Plums 

Grapefruit 

Oranges 

Cranberries 

Black- 

Pears 

Apricots 

Blueberries 

Bananas 

1 

. 

berries 

Cherries 

Goose- 

Currants 

1*; 

berries 
Peaches 
Pineapple 
Water- 
melon 

Raspberries 
Huckle- 
berries 

Butternuts 

Brazil  nuts 

Almonds 

Peanuts 

Pignolias 

Black 

English 

1 

walnuts 

walnuts 

il 

Hickory 

Beechnuts 

40% 

Pecans 

Pistachios 

Chestnuts 

Filberts 

Pine  nuts 

tj      Unsweetened   and   unspiced 
"^  pickle,    clams,     oysters,     scal- 


*  Reckon  available  carbohydrates 
in  vegetables  of  5%  group  as  3%, 
of  10%  group  as  6% 


^  lops,  Uver,  fish  roe 

30  grams  (1  oz.)  contains  approximately 


Oatmeal,  dry  weight  .  .  . 
Meat  (uncooked  ham)  .  .  . 
Meat  (cooked  ham)    .... 

Broth 

Potato 

Bacon        

Cream,  40% 

Cream,  20% 

Milk 

Bread 

Butter 

Egg  (one) 

Brazil  nuts 

Orange  or  grapefruit  (one)  .     . 
Vegetables,  5%  and  10%  groups 
Oysters 


Protein 
Gm. 

Fat 
Gm. 

Carbohy- 
drate 
Gm. 

5 

2 

20 

6 

3 

0 

8 

5 

0 

0.7 

0 

0 

1 

0 

6 

5 

15 

0 

1 

12 

1 

1 

6 

1 

1 

1 

1.5 

3 

0 

18 

0 

25 

0 

6 

6 

0 

5 

20 

2 

0 

0 

10 

0.5 

0 

1  or  2 

6 

1 

4 

Calories 


110 

50 

75 
3 

25 
155 
120 

60 

20 

90 
240 

75 
210 

40 
6  or  10 

50 


348 


DIETETICS  FOR  NURSES 


TABLE  XXIII 9 

Carbohydrate  equivalent  of  1  slice  of  white  bread  (1  oz.  or  30  gm.) 
containing  approximately  15  gm.  of  starch 


Uncooked 

Household 

Gm. 

Cooked 

Household 

Gm. 

Flours,  etc 

• 

Measure  ^° 

Vegetables 

Measure 

Barley 

1  h.  tbs. 

21 

Artichokes 

1  medium 

320 

Buckwheat 

1  h.  tbs. 

19 

Beans   (baked 

Corn  meal 

1  h.  tbs. 

20 

canned) 

2  h.  tbs. 

75 

Farina 

1  h.  tbs. 

20 

Beans,  lima 

U  tbs. 

50 

Hominy  .     . 

1  h.  tbs. 

18 

Beets    .     .     . 

6  tbs. 

200 

Macaroni 

1  h.  tbs. 

20 

Carrots      .     . 

13  tbs. 

446 

Noodles   .     . 

1|  h.  tbs. 

20 

Okra     .     .     . 

4  tbs. 

200 

Oatmeal 

1  h.  tbs. 

22 

Onions .     .     . 

3  tbs. 

300 

Rice    .     .     . 

1  h.  tbs. 

18 

Parsnips    .     . 

4  slices 

120 

Rye  flour 

1  h.  tbs. 

18 

Peas,  green 

3  h.  tbs. 

100 

Spaghetti 

li  tbs. 

20 

Potatoes 

Vermicelli     . 

H  tbs. 

21 

(baked)       . 

^  medium 

60 

Wheat  flour . 

1  tbs. 

20 

Potatoes 

(boiled) .     . 

^  medium 

70 

Potatoes 

(mashed)    . 

l|h.tbs. 

80 

Potatoes,  sweet 

(boiled) .     . 

^  medium 

35 

Squash       .     . 

2  h.  tbs. 

100 

Turnips     .     . 

3 

210 

Bread  and 

Cooked  Cereal 

Crackers 

Force     .     . 

5  h.  tbs. 

18 

Bread.     .     .     . 

1  sUce 

30 

Farina   .     . 

2-1  h.  tbs. 

125 

Breakfast     bis- 

Grapenuts . 

li  h.  tbs. 

20 

cuit,    Huntly 

Hominy 

U  h.  tbs. 

90 

and  Palmer   . 

3 

18 

Macaroni    . 

2  h.  tbs. 

100 

Corn  bread  .     . 

1  slice 

32 

Oatmeal     . 

2i  h.  tbs. 

130 

Roll,  Vienna      . 

3 

18 

Rice  .     .     . 

^  h.  tbs. 

60 

Zwieback      .     . 

U 

20 

Shredded 

Fruits 

wheat 

Apple  .     .     . 

1  medium 

120 

biscuit    . 

4 
4 

22 

Apricots    .     . 

2  large 

120 

Dried  Fruit 

Banana  (with- 

Apples  .     . 

3  small 

22 

out  skin)    . 

^  medium 

75 

Apricots     . 

3  large 

24 

Cherries    .     . 

90 

Currants     . 

iH-tbs. 

20 

Currants  . 

5  h.  tbs. 

120 

Dates     .     . 

3 

19 

Grape  fruit    . 

§  small 

150 

Figs        .     . 

1  large 

12 

Huckleberries 

3|  tbs. 

90 

Prunes  .     . 

2  large 

24 

Lemons     .     . 

2  medium 

210 

Raisins  .     . 

10  large 

23 

'  Table  devised  by  H.  O.  Mosenthal  showing  accessory  diets  rich  in  carbohy- 
drates.    "  Medical  Clinics  of  North  America,"  July,  1917. 
'0  "h"  represents  household  measure. 


DIABETES  MELLITUS 


349 


TABLE  XXIll  — Continued 


Fruits 

Household 
Measure 

Gm. 

Milk  and 
Cream 

Household 
Measure 

C.C. 

Muskmelon   . 

i 

300 

Buttermilk 

1|  tumbler 

300 

Nectarine 

1 

100 

Cream,  16% 

1|  tumbler 

300 

Olives  (green) 

20 

180 

Cream,  40% 

1|  tumbler 

300 

Orange      .     . 

f  large 

150 

Koumiss     . 

1^  tumbler 

300 

Peaches     .     . 

1|  medium 

150 

Whole  milk 

1§  tumbler 

300 

Pear     .     .     . 

1  small 

100 

Nuts 

Grams 

Pineapple 

3  slices 

150 

Almonds     . 

60 

90    . 

Plums  .     .     . 

3  medium 

75 

Brazil    .     . 

30 

180 

Raspberries   . 

4^  h.  tbs. 

120 

Chestnuts 

Strawberries 

8  h.  tbs. 

200 

(roasted) 

15 

40 

Watermelon  . 

large  slice 

300 

Cocoanut 

1  slice 

(3  X2in.) 

50 

Filberts      . 

100 

110 

Peanuts 

40 

80 

Pecans  .     . 

35 

110 

Pistachios 

190 

95 

Walnuts     . 

30 

125 

TABLE   XXIV" 

Caloric  equivalent  of  10  gm.  steak  in  carbohydrate-free 
meat  or  fish 


Food 

Gm. 

Fat 
Gm. 

Protein 
Gm. 

Calories 

Steak 

10 

1.0 

2.4 

19 

Roast  beef    . 

5 

1.4 

1.1 

18 

Tongue     .     . 

7 

1.4 

1.6 

20 

Lamb  chop  . 

5 

1.5 

1.1 

18 

Roast  lamb  . 

8 

1.3 

1.6 

20 

Sweetbreads 

11 

0.1 

4.4 

19 

Boiled  ham  . 

7 

1.4 

1.5 

19 

Fried  ham     . 

5 

1.7 

1.1 

20 

Roast  pork   . 

9 

0.9 

2.6 

19 

Bacon .     .     . 

9 

1.7 

0.9 

20 

Chicken    .     . 

10 

1.0 

2.4 

19 

Duck  .     .     . 

9 

1.3 

1.8 

19 

Guinea  hen 

12 

0.8 

2.8 

19 

Squab .     . 

9 

1.1 

2.1 

19 

Turkey     .     . 

7 

1.3 

2.0 

20 

Bluefish    . 

13 

0.6 

3.5 

20 

Hahbut    . 

16 

0.7 

3.3 

20 

Mackerel 

15 

1.0 

2.5 

20 

Sardines  in  oil 

7 

1.4 

1.6 

20 

11  Mo 

sen 

thai :  " 

Medical  Clinic 

s  of  North  An 

lerica,"  July, 

1917. 

350  DIETETICS  FOR  NURSES 

Approximate  equivalent  in  30  c.c.  (1  oz.)  of  whisky  in  liquors 
containing  2  per  cent  or  less  of  carbohydrates 


Gin,  rum,  brandy 

Claret,  Burgundy  Hock,  Rhine  and 
Moselle  wines 


Household 
Measure 


CARBOHYDRATE-FREE   MENUS 

The  following  menus  are  suggested  as  meeting  the  carbohydrate- 
free  diet  requirements  with  a  nutrient  value  of  from  200  to  500 
calories. 
Breakfast  —  Black  coffee  (cream,  20  c.c.) 

Bacon,  2  slices  (1  oz.) 30  grams 

Egg-1 

Dinner  —  Broth,  6  ounces 180  grams 

Steak,  1  small  piece,  1|  cz.    .     .     .  40  grams 

Stewed  tomatoes,  3 J  oz.        .      .     .  100  grams 

Lettuce  (lemon  juice  and  olive  oil)  25  grams 

Supper  —  Broth 180  grams 

Whitefish 40  grams 

Spinach 100  grams 

Cabbage  salad 100  grams 

Coffee 
Breakfast  —  ^  grapefruit 
1  egg 

Bacon 40  grams 

Coffee 50  grams 

Cream "20  c.c. 

Dinner  —  Broth 180  c.c. 

Kohl-rabi 100  grams 

Lettuce 25  grams 

Cheese  salad 50  grams 

Roast  beef 40  grams 

Coffee 

Butter 5  grams 


DIABETES  MELLITUS 

Supper  —  Cold  chicken 25  grams 

Baked  tomatoes 100  grams 

Water  cress 50  grams 

Coffee 

Cream 20  c.c. 

Butter 5  grams 


351 


TABLE  XXV 


Material 

Measure 

Protein 
Gm. 

Fat 
Gm. 

Carbo- 
hydrate 
Gm. 

Calories 

Apple      .... 

1  medium 
(150  gm.) 

.5 

.5 

16 

70 

Almonds  12  ^     ^     ^ 

10  small  (10  gm.) 

2 

5 

2 

63 

Apricots  (dried)    . 

1  oz.  (30  gm.) 

1.5 

.28 

17.5 

78 

Asparagus   .     .     . 

6  large  stalks 
(74  gm.) 

1.3 

.14 

2.5 

16 

Bacon  (raw)  ^2 .     . 

4slices,  6in.  long, 
2  in.  wide 

10 

64 

636 

Bacon  (cooked)  ^^ . 

4  slices,  Gin.  long, 
2  in.  wide 

10 

32  to  46 

388  to  468 

Beef  juice  "      .     . 

100  gm. 

4.9 

.6 

25 

Beef  roast  »2     .     . 

1|  in.  X  i  in. 

6 

7 

89 

Cheese  ^2 

(Neufchatel)    . 

1  cheese  2j  in. 
Xl^in.Xliin. 

16 

23 

1 

284 

Cream,  gravity 

16%     .... 

1  glass  (7  oz.) 

5 

32 

10 

359 

Cream,  40%    .     . 

30  c.c.  (2  tbs.) 

.6 

12 

1 

114 

Cracker     (Uneeda 

biscuit)     .     .     . 

1  biscuit 

1 

.5 

1 

16 

Dry  peptonoids  ^^ 

1  tbs. 

6 

8 

57 

Egg 

1  medium  (45  to 

50  gm.) 

54 

4.2 

60 

Fowl        .... 

3^  oz.  (100  gm.) 

19.3 

16.3 

224 

Grapefruit   .     .     . 

h 

5 

20 

Ham  (lean)       .     . 

50  gm. 

12.4 

7.1 

113 

Lemon  juice  ^*  .^   . 

3  tbs.  (43  gm.) 

4.2 

19 

Lemon  jelly ^^   .     . 

3  oz.  (90  gm.) 

2.6 

1.4 

16 

"  "Starvation  Treatment  of  Diabetes,"  by  Hill  and  Eckman. 

"  "Practical  Dietetics,"  by  Alidia  Pattee. 

"  "Food  for  the  Sick,"  p.  62,  by  Strouse  and  Perry. 

"  Sweetened  with  saccharine. 


352 


DIETETICS  FOR  NURSES 
TABLE   :K'KY  — Continued 


Material 

Measure 

Protein 
Gm. 

Fat 
Gm. 

Carbo- 
hydrate 
Gm. 

Calories 

Milk  (whole)    .     . 

1    glass    (8    oz.) 

240  c.c. 

7.9 

9.6 

10 

158 

Oatmeal  16   .     .     . 

1  tbs.  (50  gm.) 

1 

6 

33 

Oatmeal       .     .     . 

\  cup  (3.6  oz.) 

2.1 

.1 

8.2 

50 

Potato  16  (size  large 

1  (100  gm.) 

2 

.8 

83 

egg) 

5%  vegetable  ^^  un- 

cooked     .     .     . 

1  tbs. 

2.5 

10 

5%  vegetable 

(boiled  once)     . 

1  tbs. 

1.7 

7 

5%  vegetable 

(boiled  thrice)  . 

1  tbs. 

1 

4 

Orange    .... 

1  large 

1.7 

.2 

22.7 

100 

Orange  ^^      .     .     . 

1  medium 

1 

13 

57 

Increasing  the  Diet.  —  The  following  menus  show  the  manner 
in  which  the  diet  is  increased  after  the  starvation  treatment : 

First  Day 

Approximately  150  grams  of  vegetables  with  tea  or  coffee; 
value :  protein  2,  fat  trace,  carbohydrate  4. 

Breakfast  —  String  beans 20  grams 

Celery  hearts 20  grams 

Lunch  —  Spinach 25  grams 

Lettuce 25  grams 

Supper  —  Tomatoes 25  grams 

Cucumbers 25  grams 

Second  Day 

Three  eggs,  150  grams  of  5%  vegetables,  tea  or  coffee ;  value 
approximately :  protein  18,  fat  12,  carbohydrate  4,  calories  198. 

Breakfast  —  1  poached  egg 

Spinach  or  beet  tops 50  grams 

Coffee  or  tea 

*^  "Starvation  Treatment  of  Diabetes,"  by  Hill  and  Eckman. 


DIABETES  MELLITUS  353 

Dinner  —  1  hard-cooked  egg 

String  beans 25  grams 

Lettuce 25  grams 

Tea 
Supper  —  1  soft-cooked  egg 

Asparagus  tips 25  grams 

Tomatoes 25  grams 

Third  Day 

Approximately  19  grams  protein,  15  grams  fat,  5  grams  car- 
bohydrate, 230  calories. 

Breakfast  —  1  egg 

String  beans 50  grams 

Tomatoes 25  grams 

Coffee 

Dinner  —  Cauliflower 50  grams 

Celery 50  grams 

Tea 

Supper  —  Asparagus      . 75  grams 

Lettuce 50  grams 

Fourth  Day 

Approximately  26  grams  protein,  15  grams  fat,  10  grams  car- 
bohydrate, 279  calories.  * 

Breakfast  —  1  egg 

String  beans 75  grams 

Coffee  with  cream 15  c.c. 

Dinner  —  Tomato  bouillon 6  oz.  (180  c.c.) 

1  ^gS 

Asparagus 75  grams 

Lettuce 25  grams 

Tea 
Supper  —  1  egg 

Celery 50  grams 

Cauliflower 100  grams 

2a 


354  DIETETICS  FOR  NURSES 

Fifth  Day 
Approximately  20   grams   protein,   46   grams   fat,    15   grams 
carbohydrate. 
Breakfast  —  Egg  omelet  (1  egg) 

Butter 10  grams 

Vegetable  hash 100  grams 

Coffee  or  tea 

Cream 15  grams 

Dinner  —  Chicken  broth 180  c.c. 

1  poached  egg 

Tomatoes 100  grams 

Tea 
Supper  —  1  soft-cooked  egg 

Spinach 100  grams 

Cucumbers 50  grams 

Tea  or  coffee 

Cream 15  grams 

Sixth  Day 
Breakfast  —  i  grapefruit 
legg 

Butter 5  grams 

Spinach 50  grams 

Coffee 

•     Cream 15  grams 

Dinner  —  Broth 180  grams 

Fish 50  grams 

String  beans 100  grams 

Lettuce 50  grams 

Asparagus .      50  grams 

Supper  —  2  eggs 

Tomato,  baked  (1  medium).     .     .      75  grams 

Cabbage  salad 75  grams 

Tea 

Cream 15  grams 

Approximately  33  grams  protein,  35  grams  fat,  12  grams  carbo- 
hydrate, 495  calories. 


DIABETES  MELLITUS  355              i 

Seventh  Day 

Breakfast  —  ^  grapefruit  ' 

2  eggs  I 

Butter 10  grams                           ^ 

Coffee 

Cream 15  grams                          1 

Dinner  —  Beef  broth 180  grams                           < 

1  lamb  chop 50  grams                           ] 

CauHflower 100  grams 

Tomato 150  grams                           ' 

Lettuce 50  grams                          ^ 

Butter 10  grams                          ; 

Supper  —  1  egg  | 

Tuna  salad 50  grams                           ■ 

String  beans 100  grams                       ^   ' 

Butter 5  grams 

Tea  j 

Approximately  38  grams  protein,  45  grams  fat,  17  grams  carbohy-  ; 
drate,  625  calories. 

Eighth  Day  | 
Approximately  32  grams  protein,  16  grams  fat,  20  grams  car- 
bohydrate, 625  calories. 
Breakfast — 1  egg 

String  beans 100  grams 

Raw  tomatoes 100  grams                           ] 

Coffee  ! 

Cream 15  grams 

Dinner  —  Chicken 50  grams                           , 

Cabbage 100  grams                           \ 

Asparagus 100  grams 

Water-cress  salad 50  grams                           !, 

Tea  ] 

Supper  — 1  egg  \ 

Greens 100  grams 

Celery  salad 50  grams                           i 

Tea  I 

Cream 15  grams                           i 


356  DIETETICS  FOR  NURSES 

Nurse's  Directions  for  Collecting  and  Testing  the  Urine  in 
Diabetes  Mellitus.  —  The  first  urine  voided  in  the  morning  at 
7  A.M.  should  be  thrown  away,  after  which  the  entire  quantity 
during  the  ensuing  twenty-four  hours,  inc^luding  that  at  7  a.m. 
the  following  morning,  should  be  collected  in  a  thoroughly 
clean,  wide-mouth  bottle  sufficiently  large  to  contain  the  en- 
tire quantity.  This  should  be  kept  in  a  cool  place  to  prevent 
decomposition.  After  the  urine  has  been  measured,  four  or 
five  ounces  are  removed  for  testing  purposes.  There  is  no 
necessity  for  having  an  elaborately  equipped  laboratory  for 
making  the  simple  tests  of  the  diabetic  urine.  The  nurse  is  only 
required  to  make  the  simple  tests,  leaving  the  more  elaborate  one 
for  the  physician.  The  articles  necessary  for  these  tests  must  be 
kept  perfectly  clean  in  order  to  make  the  tests  accurate.  The 
bottle  in  which  the  urine  is  collected  must  be  washed  and  sterilized 
daily  before  the  collection  begins.  One  small  three-inch  white 
enameled  or  porcelain  dish,  one  10  c.c.  graduated  pipette,  6  test 
tubes,  1  small  alcohol  lamp  or  Bunsen  burner,  1  box  of  sodium 
carbonate,  1  box  talcum,  and  the  reagents  necessary  for  making 
the  test,  namely,  Benedict's  solution,  Fehling's  solution,  and 
Haines's  solution. 

Benedict's  Qualitative  Sugar  Test.  —  Boil  5  c.c.  of  Benedict's 
solution ;  add  8  drops  of  urine  to  be  examined ;  hold  the  tube 
over  the  flame  and  allow  to  boil  vigorously  for  3  minutes  and  set 
aside  to  cool  of  itself.  In  the  presence  of  sugar  the  entire  solution 
will  be  filled  with  a  precipitate  which  may  be  greenish,  yellow,  or 
red,  according  id  the  amount  of  sugar  present.  When  the  per- 
centage of  sugar  is  low  (under  0.3%)  the  precipitate  will  form  only 
upon  the  cooling  of  the  solution.  If  there  is  no  sugar  present,  the 
solution  will  either  remain  clea,r  or  show  a  slight  turbidity,  due  to 
the  precipitation  of  urates.  The  nurse  must  remember  that  to  be 
useful  the  test  must  be  made  accurately.  There  must  never  be 
more  than  10  drops  of  urine,  and  8  drops  is  the  usual  quantity. 
The  boiling  must  be  vigorous  and  the  solution  allowed  to  cool 
spontaneously. 

Fehling's  Test  for  Sugar. — Fehling's  alkaline  solution  and  Feh- 


DIABETES  MELLITUS  367 

ling's  copper  solution  must  be  kept  in  separate  bottles  until  ready 
for  use.  Then  about  2  c.c.  of  Fehling's  alkaline  solution  is  poured 
into  a  test  tube  and  2  c.c.  of  Fehling's  copper  solution  is  added. 
This  is  diluted  with  hydrant  water  to  8  c.c.  Half  of  this  quantity 
is  sufficient  for  the  test.  The  upper  half  of  the  solution  is  boiled 
over  flame  (gently  agitated  while  heating),  and  while  still  boiling 
a  few  drops  of  urine  are  added.  If  no  change  appears,  it  is  boiled 
again  and  a  few  drops  more  of  urine  are  added.  If  a  reddish  pre- 
cipitate appears,  sugar  is  present.  The  chemical  reaction  taking 
place  is  the  reduction  of  copper  sulphate  to  cuprous  oxide.  Some- 
times a  partial  reduction  occurs  when  urates  are  in  excess,  but 
once  having  seen  the  real  reduction,  a  partial  one  cannot  mislead 
the  examiner. 

Haines's  Test.  — Pour  1  teaspoonful  of  Haines's  solution  into  a 
test  tube  and  boil  gently  over  a  Bunsen  burner ;  add  6  or  8  drops 
of  urine  and  again  heat  to  boiling.  A  yellow  or  red  precipitate 
will  indicate  the  presence  of  glucose. 

QUANTITATIVE   TEST   FOR   SUGAR 

Benedict's  Test.^^ — The  simple  quantitative  test  for  sugar  is  the 
one  devised  by  Benedict.  This  is  simpler  than  the  polariscopic 
examination  and  better  suited  for  ordinary  use. 

Place  5  c.c.  of  Benedict's  quantitative  solution  in  a  small 
dish,  add  a  little  less  than  one-fourth  of  a  teaspoonful  of  sodium 
carbonate  and  one-eighth  of  a  teaspoonful  of  talcum  and  add  10 
c.c.  of  water.  Dilute  urine  (1  part  urine  to  9  parts  water)  except 
where  the  qualitative  test  showed  a  low  percentage  of  sugar,  that 
is,  when  the  precipitate  turns  green  instead  of  yellow,  in  which 
case  it  will  be  unnecessary  to  dilute  the  urine.  Place  dish  over 
burner  and  bring  the  contents  to  a  boil.  Pour  the  urine  into  a 
graduated  pipette.  Now  add  the  urine  drop  by  drop  to  the  con- 
tents in  the  dish  until  the  blue  cplor  entirely  disappears.  This 
test  should  be  done  over  several  times  to  assure  an  accurate  cal- 
culation.    The  calculation  is  made  as  follows  :  5  c.c.  of  Benedict's 

""Treatment  of  Diabetes  Mellitus,"  pp.  182-183,  by  Jodin. 


358  DIETETICS  FOR  NURSES 

quantitative  copper  solution  are  reduced  by  0.01  gram  of  glu- 
cose, consequently  the  quantity  of  undiluted  urine  required  to 
reduce  5  c.c.  Benedict's  solution  contains  0.01  gram  of  glucose. 

— — X  100  =  per  cent,    x  =  c.c.  of  undiluted  urine. 

X 

Example :  1500  c.c.  urine  in  24  hours. 

5  c.c.  used  to  reduce  (decolorized)  Benedict's  solution 

^  X  100  =  0.2  per  cent. 
5 

1500  X  0.002  (0.2  per  cent)  =  3  grams  of  sugar  in  24  hours. 

Example :  If  the  urine  had  been  diluted  with  9  parts  water,  in 

other  words,  10  times,  the  calculation  would  be  5  c.c.  diluted 

urine  ==  0.5  c.c.  actual  urine.     -^-^  X  100  =  2  per  cent. 

U.o 

1500  X  0.02  (2  per  cent)  =  30  grams  of  sugar  in  24  hours. 

Hill  and  Eckman  perform  the  Benedict's  quantitative  test  as 
follows :  ^^ 

Measure  with  a  pipette  25  c.c.  Benedict's  solution  into  a  por- 
celain dish,  add  5  or  10  grams  approximately  of  solid  sodic  carbon- 
ate, heat  to  boiling,  and  while  boiling,  run  in  urine  until  a  white 
precipitate  forms,  then  add  urine  more  slowly  until  the  last  trace 
of  blue  disappears.  The  urine  should  be  diluted  so  that  not  less 
than  10  c.c.  will  be  required  to  amount  of  sugar  which  25  c.c.  of 
reagent  is  capable  of  oxidizing. 

Calculation :  5  divided  by  number  of  cubic  centimeters  of  urine 
run  in  equals  per  cent  of  sugar. 

Fermentation  Test  for  Quantity  of  Sugar  in  Urine.  —  If  the 
urine  is  70°  F.  (room)  temperature  when  the  specific  gravity  is 
taken  at  both  the  beginning  and  end  of  the  test,  it  will  assure 
accuracy. 

To  100  c.c.  of  urine  of  known  specific  gravity,  add  one-fourth 
of  fresh  yeast  cake  thoroughly  broken  up.  Mix  thoroughly  and 
set  aside  at  a  temperature  between  85°  and  95°  F.  for  twenty- 
four  hours,  after  which  time  test  with  Benedict's  or  Fehling's  solu- 
tions.    If  reduction  is  obtained,  it  will  be  necessary  to  allow  the 

w  "Starvation  (Allen)  Treatment  for  Diabetes  Mellitus,"  by  Hill  and  Eckman. 


DIABETES  MELLITUS  359 

fermentation  to  continue  until  it  is  complete.  When  no  further 
reduction  is  obtained,  the  specific  gravity  is  taken  after  the  urine 
has  reached  a  temperature  of  76°.  The  difference  in  the  specific 
gravity  at  the  beginning  and  end  of  the  test  multiplied  by  0.23 
gives  the  percentage  of  sugar  in  the  urine. 

The  following  formulas  represent  the  various  solutions  used  in 
the  above  test : 

Benedict's  Qualitative  Solution 

Gm.  or  ex. 

Copper  sulphate  (pure  crystals) 17.3 

Sodium  or  potassium  citrate 173.0 

Sodium  carbonate  (anhydrous) 100.0 

Distilled  water  to  make 1000.0 

Feeling's  Solution  ,_^ 

(1)  Copper  Sulphate  Solution : 

34.65  grams  copper  sulphate  dissolved  in  water  and 
suj05cient  water  added  to  make  500  c.c. 

(2)  Alkaline  Solution : 

125  grams  potassium  hydroxide. 

173  grams  Rochelle  salts  dissolved  in  water  q.s.  to  make 
500  c.c. 
Keep  solution  in  separate  bottles  and  mix  in  equal  quantities 
when  ready  to  use. 

Haines's  Solution 

Copper  sulphate  (pure) 30  grams 

(dissolved  in  -^  oz.  (15  c.c.)  distilled  water) 
Add  ^  oz.  pure  glycerine,  mix  thoroughly,  and  add  5  oz.  liquor 
potassse. 

Benedict's  (Quantitative)  Solution 

Copper  sulphate  (pure  crystals) 18  grams 

Sodium  carbonate  (crystallized)  (or  100  grams  of 

anhydrous  salt) 200  grams 


360  DIETETICS  FOR  NURSES 

Sodium  or  potassium  citrate 200  grams 

Potassium  sulphocyanide 125  grams 

5  per  cent  solution  of  potassium  ferrocyanide  .     .        5  c.c. 

Distilled  water  to  make  total  volume  of  1000  c.c. 

Dissolve  the  carbonate,  citrate,  and  sulphocyanide  with  the 
aid  of  heat  and  enough  water  to  make  800  c.c.  of  mixture.  (Filter, 
if  necessary.)  Weigh  exactly  the  copper  sulphate  crystals  and 
dissolve  in  100  c.c.  of  water,  now  add  it  to  the  first  solution ;  stir- 
ring constantly.  Add  the  ferrocyanide  solution;  cool  and  dilute 
to  exactly  1  liter. 

50  mg.  (0.050  gm.)  of  sugar  will  reduce  25  c.c.  of  the  above 
solution. 

Gerhardt's  Ferric  Chloride  Reaction  for  Diacetic  Acid.  —  To 
10  c.c.  of  fresh  urine,  add  carefully  a  few  drops  at  a  time  of  un- 
diluted aqueous  solution  of  ferric  chlorid  U.  S.  P.  A  precipitate 
of  ferric  phosphates  first  forms,  but  upon  the  addition  of  a  few 
more  drops  of  the  same  solution  it  is  dissolved.  A  Burgundy  red 
(red  wine)  color  is  obtained  in  the  presence  of  diacetic  acid.  The 
depth  of  this  color  is  indicative  of  the  quantity  of  acid  present. 
Joslin  ^®  records  the  intensity  of  the  reaction  as  follows,  +,  ++> 
+  +  +,  or -h  +  +  -^. 

According  to  Joslin,  it  must  be  remembered  that  a  similar  re- 
action is  obtained  in  the  urine  of  individuals  taking  salicylates, 
antipyrin,  cyanates,  or  acetates,  but  it  is  a  simple  process  to  dif- 
ferentiate between  the  color  produced  as  a'  result  of  diacetic  acid 
and  that  produced  by  the  above-mentioned  drugs.  If  the  solu- 
tion is  boiled  for  two  minutes,  the  color  from  diacetic  acid  will  dis- 
appear, owing  to  the  unstableness  of  that  substance,  while  that 
from  the  drugs  will  remain  unchanged. 

Test  for  Acetone.  —  Pour  5  c.c.  of  urine  to  be  tested  into  a  test 
tube,  add  a  crystal  of  sodium  nitroprusside,  acidify  with  glacial 
acetic  acid,  shake  well,  and  then  make  alkaline  with  ammonium 
hydrate.     The  presence  of  acetone  is  indicated  by  a  purple  color. 

Tests  for  albumen  will  be  found  in  the  chapter  on  Urinalysis. 

"  "Treatment  of  Diabetes  MelHtus,"  p.  186,  by  Joslin. 


DIABETES  MELLITUS  361 

Diabetes  Mellitus  is  a  disease  in  which  the  body  becomes 
more  or  less  unable  to  utilize  the  sugars  and  starches,  consequently 
there  is  an  abnormal  amount  of  glucose  in  the  urine. 

Manufacture  of  Sugar  in  the  body  from  other  food  constit- 
uents besides  carbohydrates  has  been  proved  with  regard  to  pro- 
teins, hence  the  intake  of  nitrogenous  substances  must  be  re- 
stricted in  diabetes  —  to  a  less  extent,  however,  than  the  sugars 
and  starches. 

Acetone  Bodies.  —  Diacetic  acid,  oxybutyric  acid,  and  acetone 
develop  in  diabetes  as  a  result  of  the  breaking  down  of  the  fats 
and  the  lack  of  certain  neutralizing  agents  found  chiefly  in  car- 
bohydrate foods. 

Acidosis  is  a  form  of  intoxication  due  to  the  retention  of 
these  toxic  acids  in  the  body.  If  not  combated  and  overcome, 
it  will  result  in  the  diabetic  coma  which  is  fatal  in  so  many  cases. 

Allen  Treatment  consists  of  a  period  of  complete  starvation 
in  order  to  allow  the  urine  to  become  sugar  free,  after  which  a  re- 
education of  the  organs  by  means  of  determining  and  utilizing  the 
patient's  tolerance  for  each  food  constituent  is  begun.  The  star- 
vation period  lasts  from  two  to  four  days.  The  reeducation  of 
the  organs  begins  with  the  giving  of  certain  green  vegetables,  con- 
taining five  per  cent  carbohydrates,  which  are  further  reduced  in 
the  sugar  content  by  boiling  through  three  waters.  As  the  body 
shows  by  urinalysis  an  improvement  in  its  ability  to  utilize  the 
carbohydrates,  they  are  increased  in  amount  and  type,  passing 
upward  through  the  foods  containing  a  higher  percentage  of  starch, 
such  as  potatoes,  oatmeal,  and  bread. 

Preliminary  Diets  are  necessary  in  certain  cases,  especially 
if  there  is  already  an  evident  acidosis.  The  fats  are  omitted  first, 
then  the  proteins  and  part  of  the  carbohydrates ;  then  all  of  the 
carbohydrates. 

Alkalies  are  only  given  under  the  direction  of  a  physician. 
Much  harm  may  be  done  by  the  indiscriminate  use  of  soda  and 
like  alkalies. 

Mild  Cases  are  at  times  treated  merely  by  reducing  the 
carbohydrates,  by  reducing  the  sugar  and  reducing  the  bread 


362  DIETETICS  FOR  NURSES 

allowance  25  grams  a  day  until  the  urine  is  sugar  free.  However, 
the  starvation  method  shows,  as  a  rule,  more  rapid  and  more 
lasting  results. 

Examination  of  Urine  is  obligatory  and  should  be  made  at 
frequent  intervals.  The  amount  voided,  the  color,  odor,  specific 
gravity,  and  chemical  composition  must  be  accurately  determined 
in  order  that  one  may  intelligently  cope  with  the  disease. 

Training  for  Diabetic  Nursing.  —  So  much  depends  upon  the 
administration  of  the  treatment  in  this  pathological  condition 
that  in  many  hospitals  special  training  is  being  given  to  the  nurses 
in  the  care  of  diabetic  patients  that  they  may  be  able  intelli- 
gently to  carry  out  the  necessary  regime,  both  in  the  hospital  and 
in  private  practice. 

Probably  in  no  other  disease  is  the  need  for  an  intelligent  and 
well-trained  nurse  so  clearly  demonstrated.  Since  the  treatment 
is  not  a  question  of  drugs,  but  diet.  Nature  must  be  helped  to  help 
herself,  and  in  no  other  way  is  this  possible  but  by  careful  and 
vigilant  attention  to  details. 

Recognition  of  Sjmiptoms.  —  No  symptom  is  too  slight  to  be 
overlooked,  since  in  this  disease  the  seemingly  trivial  symptoms 
may  readily  indicate  the  approach  of  the  most  dreaded  of  all  com- 
plications —  diabetic  coma. 

Special  Points.  —  It  is  necessary  for  the  nurse  to  familiarize 
herself  with  all  the  phases  of  the  disease,  that  she  may  be  com- 
petent to  cope  with  the  trouble  when  it  arises.  For  this  reason 
the  following  rules  and  regulations  are  laid  down. 

Composition  and  Nutrient  Value  of  Food.  —  It  is  absolutely 
essential  that  the  nurse  should  know  the  composition  and  nutrient 
value  of  the  various  food  materials  in  order  to  be  able  to  calcu- 
late accurately. 

The  Relation  of  Foods.  —  To  be  able  to  weigh  and  measure 
every  article  of  food  included  in  the  dietary  and  realize  the  rela- 
tion which  they  bear  to  each  other  in  order  to  be  able  to  vary  the 
diet  by  substituting  one  food  for  another  of  like  composition,  or 
to  substitute  in  the  proper  quantity  a  food  of  higher  carbohydrate 
content  for  one  containing  less  of  that  food  constituent. 


DIABETES  MELLITUS  363 

The  Metric  System.  —  She  must  learn  the  metric  system  to  be 
able  to  calculate  any  diabetic  diet. 

Symptoms.  —  She  must  be  able  to  recognize  symptoms  both 
from  the  findings  resulting  from  the  urinalysis  and  from  those 
manifested  otherwise  by  the  patient. 

The  Record.  —  She  must  keep  an  absolute  record  of  all  that 
occurs  during  the  course  of  treatment  and  instantly  report  any 
unusual  happening. 

Instructing  the  Patient.  —  She  must  instruct  the  patient  in  the 
rules  for  weighing  and  measuring  and  calculating  the  diet  and  for 
making  the  simple  tests  for  sugar  in  the  urine.  She  must  also 
instruct  her  patient  in  the  recognition  of  symptoms,  especially 
those  which  may  herald  the  approach  of  a  diabetic  coma,  namely, 
restlessness,  loss  of  appetite,  unusual  fatigue,  discomfort,  painful 
or  deep  breathing,  excitement,  drowsiness,  vertigo,  and  headache, 
any  of  which  in  themselves  seem  slight  and  insignificant,  but  which 
in  connection  with  the  diabetic  condition  may  be  anything  but 
trivial.  Any  failure  on  the  part  of  the  nurse  to  report  the  develop- 
ment of  such  symptoms  would  be  unpardonable. 

Method  of  Collecting  the  Urine.  —  The  nurse  should  collect 
all  the  urine  voided  during  the  twenty-four  hours,  beginning  at 
7  A.M.  This  should  be  kept  in  a  bottle  sufficiently  large  to  con- 
tain the  entire  quantity.  The  bottle  should  be  kept  in  a  cool 
place  to  prevent  decomposition  taking  place  in  the  urine ;  further 
precaution  may  be  used  by  adding  a  teaspoonful  of  some  simple 
preservative,  such  as  chloroform  or  toluol.  When  chloroform  is 
used  the  specimen  of  urine  will  have  to  be  heated  before  it  is  tested 
for  sugar.  After  the  urine  is  collected,  it  should  be  carefully  meas- 
ured and  the  entire  quantity  recorded.  The  nurse  must  warn 
the  patient  of  the  necessity  for  taking  account  of  the  urine  voided 
with  the  stools.  After  the  collection  is  made,  four  or  five  ounces 
are  taken  out  for  analysis. 

Urine  Tests.  —  It  is  advisable  to  make  the  tests  in  the  morning ; 
those  for  sugar  and  diacetic  acid  should  be  made  every  day  or, 
in  some  cases,  every  other  day,  as  directed  by  the  physician,  and 
those  for  ammonia  and  albumen  about  once  a  week. 


364  DIETETICS  FOR  NURSES 

Weighing  the  Patient.  —  Patient  should  be  weighed  each  day 
before  breakfast,  and  the  weight  of  the  clothes  also  carefully  re- 
corded separately. 

The  Bowels  must  move  daily,  even  if  it  is  necessary  to  resort 
to  mild  laxatives  or  an  enema.  Seidlitz  powders  contain  bicar- 
bonate of  soda  and  according  to  Joslin  lead  to  the  appearance  of 
diacetic  acid  in  the  urine,  if  the  patient  has  a  low  carbohydrate 
tolerance.  Mineral  oil  is  at  times  used  with  benefit  to  overcome 
the  constipation. 

Formulating  and  Calculating  the  Dietary.  —  The  menus  of  the 
day  must  be  formulated  and  the  chemical  composition  and  nutrient 
value  of  the  foods  calculated.  The  vegetables  belonging  to  the 
five  per  cent  group  should  be  in  readiness  and  the  amount  to  be 
used  weighed  after  they  have  been  boiled  in  clean,  separate  water 
to  reduce  their  carbohydrate  content  still  further. 

Commercial  Diabetic  Foods.  —  It  may  be  well  to  mention  the 
danger  of  putting  faith  in  the  so-called  diabetic  foods  so  widely 
advertised.  Some  of  these  foods  are  of  undoubted  worth,  but  it 
is  never  safe  for  the  nurse  or  the  patient  to  judge  of  the  merits  of 
the  various  diabetic  foods  without  first  knowing  their  chemical 
composition,  and  not  even  then  without  the  definite  directions 
from  the  physician. 

Diabetic  Flours.  —  The  diabetic  flours  used  in  the  recipes  in- 
cluded in  this  text  have  been  approved  by  some  of  the  leading 
specialists  in  diabetes  in  this  country,  but  the  nurse  should  not 
include  them  in  the  diet  for  her  patient  unless  they  are  prescribed 
by  the  physician  in  charge. 

The  following  flours  have  been  analyzed  at  the  Experiment 
Station  of  Connecticut:  Hepco  Flour,  Lister's,  and  Barker's 
Gluten  Flour.  Biscuits  or  muffins  made  from  these  flours,  as 
well  as  Akoll  biscuit.  No.  1  Protho  Puffs,  washed  bran  muffins, 
washed  coconut  cakes,  and  almond  meal  cakes  are  palatable,  and 
furnish  agreeable  variations  when  any  such  foods  are  allowed. 

Sugar-free  Milk.  —  A  sugar-free  milk  has  been  advised  by 
Williamson.  It  is  made  from  washed  cream  as  follows  :  3  table- 
spoonfuls  of  cream  are  shaken  in  a  pint  of  water  and  set  aside  until 


DIABETES  MELLITUS  365 

the  cream  rises,  it  is  then  skimmed  off  and  mixed  with  the  white 
of  one  egg  and  diluted  with  pure  water.  This  furnishes  a  beverage 
not  unKke  milk  in  looks  and  flavor. 

Composition  and  Approximate  Weight  of  Foods.  —  The  follow- 
ing table  giving  the  measure  of  some  of  the  foods  with  their  chemi- 
cal composition  and  nutrient  value  may  be  of  assistance  to  the 
nurse  in  formulating  the  menu  for  the  diabetic  patient.  These 
values  are  approximate,  but  are  sufficiently  near  for  all  practical 
purposes.  The  vegetables  have  already  been  classified  according 
to  their  percentage  of  carbohydrates,  but  the  amount  included 
below  may  simplify  the  process  and  shorten  the  time  necessarily 
spent  in  the  preparation  of  the  diet. 

The  following  menus  are  used  after  the  diet  has  been  more  or 

less  increased : 

First  Day 

Breakfast — 1  soft-cooked  egg 
2  slices  of  bacon 

1  bran  muffin,  5  gm.  butter 
Coffee  with  15  c.c.  of  40%  cream 

Lunch  —  6  oz.  tomato  bouillon 

2  oz.  (60  gm.)  roast  lamb 
60  gm.  string  beans 

50  gm.  lettuce  and  celery  salad 
25  gm.  lemon  jelly  with  15  gm.  cream 
Dinner  —  60  gm.  chicken 

75  gm.  asparagus 

4  olives 

50  gm.  cauliflower 

30  gm.  ice  cream 

1  Lister  roll,  5  gm.  butter 

Black  coffee 

Second  Day 
Breakfast — i  grapefruit 

1  scrambled  egg 

1  Lister  roll,  8  gm.  butter 

Coffee  with  15  gm.  cream 


366  DIETETICS  FOR  NURSES 

Lunch  —  60  gm.  baked  halibut  with  10  gm.  parsley  butter 
70  gm.  cauliflower 
50  gm.  lettuce 
1  Lister  roll,  8  gm.  butter 
Tea 
Dinner  —  6  oz.  chicken  broth 
60  gm.  roast  beef 
75  gm.  cabbage 
75  gm.  string  beans 
30  gm.  coffee  jelly  with  15  gm.  cream 
Black  coffee 

Third  Day 


Breakfast  —  1  soft-cooked  egg  ] 

2  slices  bacon  ; 

1  Casoid  flour  and  bran  muffin  with  5  gm.  butte/  i 

Coffee  with  15  gm.  cream  i 

Lunch  —  100  gm.  cabbage  ■ 

40  gm.  corned  beef  j 

50  gm.  tomato  salad  1 

1  soya  meal  muffin,  8  gm.  butter  ■ 

Tea  ] 

Dinner  —  60  gm.  beefsteak  j 

75  gm.  asparagus  ; 

75  gm.  spinach  j 
30  gm.  tomato  aspic 

30  gm.  soft  (diabetic)  custard  ' 

Black  coffee  - 

Fourth  Day  'i 

Breakfast  —  1  scrambled  egg  with  20  gm.  chipped  beef  j 


1  Casoid  flour  muffin  with  8  gm.  butter 
Coffee  with  30  gm.  or  less  cream 
Lunch  —  6  oz.  tomato  bisque 
60  gm.  tuna  fish  salad 


DIABETES  MELLITUS  367 

75  gm.  vegetable  hash 
1  Lister  roll,  8  gm.  butter 
Tea 
Dinner  —  60  gm.  broiled  chicken 
75  gm.  string  beans 
75  gm.  cauliflower 
30  gm.  tomato  and  celery  salad 
30  gm.  wine  jelly,  with  15  gm.  whipped  cream 
Black  coffee 

Fifth  Day 
Breakfast  —  i  grapefruit 

1  soft-cooked  egg 
1  bran  mufiin  with  8  gm.  butter 
Coffee,  15  gm.  cream 
Lunch  —  40  gm.  broiled  beefsteak 
75  gm.  spinach 
75  gm.  boiled  onion 
1  soya  meal  muflSn  with  8  gm.  butter 
Tea 
Dinner  —  6  oz.  tomato  bouillon 

80  gm.  baked  fish  with  parsley  sauce 

75  gm.  Brussels  sprouts  with  5  gm.  butter 

1  Lister  roll  with  5  gm.  butter 

Coffee  jelly,  30  gm.,  with  15  gm.  whipped  cream 

Sixth  Day 
Breakfast  —  1  poached  egg 

2  slices  bacon 

1  bran  and  Casoid  mufiin  with  5  gm.  butter 
Coffee  with  15  gm.  cream 
Lunch  —  Ham  omelet  (1  egg,  1  tbs.  cream,  15  gm.  minced 
ham) 
75  gm.  spinach 

1  soya  meal  muffin  with  8  gm.  butter 
Tea 


368  DIETETICS  FOR  NURSES 

Dinner  —  60  gm.  beefsteak  with  1  tsp.  parsley  butter 
75  gm.  asparagus 
75  gm.  string  beans 
30  gm.  lettuce  and  celery  salad 
1  mold,  30  gm.,  Bavarian  cream 
Coffee 

Seventh  Day 

Fast 

Formulas  Used  in  Diabetic  Diets 

Cream  Soups 

The  preparation  of  Cream  Soups  for  the  diabetic  patient  differs 
from  that  used  in  other  conditions.  The  flour  and  other  thicken- 
ing agents  are  necessarily  left  out.  The  soups  are  made  by  using 
from  25  to  30  grams  of  vegetable  puree;  that  is,  5%  vegetables 
cooked  thoroughly  and  pressed  through  a  sieve.  The  liquid  part 
consists  of  *stock  and  cream ;  the  yolk  of  one  egg  is  added  to  thicken 
the  soup.  This  applies  to  all  of  the  diabetic  Cream  Soups.  The 
clear  soups  are  made  by  omitting  the  cream  and  the  egg. 

Tomato  Bisque 

1  cup  creamed  tomatoes  3  cloves 

J  cup  water  |  tsp.  salt 

1  sprig  (1  tbs.  chopped)  parsley     ^  tsp.  soda 
1|  oz.  (3  tbs.)  40%  cream 

Cook  tomatoes  with  cloves,  parsley,  and  water  for  20  minutes. 
Press  through  sieve  and  return  to  fire.  Add  soda;  when  effer- 
vescence ceases,  add  cream,  and  serve  at  once. 

Cream  of  Cauliflower 
J  cup  cauliflower  puree  }  tsp.  onion  juice  (if  desired) 

I  cup  chicken  or  beef  stock        2  tbs.  40%  cream 

Salt  and  pepper 
Add  cauliflower  to  stock,  and  allow  to  come  to  a  boil,  season 
and  add  cream.     Serve  at  once. 


DIABETES  MELLITUS  369 

Spinach  Soup 

3Qgm.  cooked  spinach  15  c.c.  40%  cream 

1  egg  yolk 

Cook  spinach  until  tender  and  press  through  a  sieve ;  add  the 
broth;  allow  to  cook  about  5  minutes  and  add  the  well-beaten 
yolk  and  cream.  Place  the  saucepan  over  hot  water  and  cook 
10  minutes.     Season  and  serve  at  once. 

Other  Cream  Soups,  except  Tomato  Bisque,  are  made  by  the 
same  recipe. 

Vegetables 

The  nurse  must  be  governed  in  the  selection  of  the  vegetables 
by  the  physician,  using  those  from  the  5%  group  until  otherwise 
ordered.  These  must  be  boiled  in  three  separate  waters  to  fur- 
ther reduce  their  carbohydratic  content. 

Cream  or  butter  is  added  to  them  when  diet  permits ;  in  the 
beginning  (after  starvation)  only  salt  or  (in  case  the  vegetable  is 
given  in  form  of  a  salad)  a  little  lemon  juice  with  a  little  salt  and 
pepper  added. 

Grated  onion,  a  small  quantity  of  celery  seed,  or  a  tiny  bit  of 
chopped  green  pepper  may  be  added  for  additional  seasoning. 
When  some  fats  are  allowed,  butter,  olive  oil,  and  cocoanut  cream 
may  be  used ;  the  latter  is  prepared  as  follows  : 

1  small  cocoanut  grated ;  this  is  washed  in  cold  water  slightly 
acidulated  with  vinegar  to  remove  the  sugar,  then  washed  to  re- 
move the  vinegar.  Over  the  washed  cocoanut  pour  1  pint  of 
boiling  water ;  allow  to  stand  until  cold  enough  to  squeeze  through 
a  cloth;  press  as  much  of  the  water  out  as  possible.  Pour  the 
water  into  a  shallow  dish  and  allow  to  stand  until  the  cream 
rises ;  skim  off  and  serve  with  lemon  juice  on  salad  as  a  dressing. 

Boiled  Corned  Beef  with  Cabbage  and  Other  Vegetables  2° 

"A  portion  containing  50-75  grams  meat  and  100  grams  of 
each  vegetable  makes  an  excellent  meal." 

20  "Treatment  of  Diabetes,"  p.  538,  by  Joslin. 
2b 


370  DIETETICS  FOR  NURSES 

Horseradish  (sauce)  is  recommended  by  Joslin  as  a  seasoning, 
and  some  pickles  made  from  group  of  5%  vegetables,  and  with- 
out sweetening. 

Curry  powder,  tarragon,  bay  leaves,  capers  may  likewise  be 
used  in  moderation  to  vary  the  monotony  of  the  diet. 

Parsley  Butter 

5  gm.  butter  1  tsp.  chopped  parsley 

Salt,  pepper,  and  |  tsp.  lemon  juice,  if  desired 

Cream  butter,  add  lemon  juice,  salt,  and  pepper.  Stir  in  parsley. 
Serve  on  meat  or  fish. 

Neufchatel  Cheese  Salad 

f  Neufchatel  cheese  1  tbs.  cream  (40%) 

J  green  pepper  1  tsp.  lemon  juice 

Season  with  salt  and  paprika  and  dress  with  Cream  Dressing. 

Cheese  Salad 

Mash  Cream  Cheese  with  fork;  add  tablespoonful  chopped 
pecan  nuts  to  f  Neufchatel  Cheese.  Season  with  salt  and  pepper 
and  dress  with  French  Dressing. 

-    Tuna  Fish  Salad 

i  cup  tuna  fish  J  cup  chopped  celery 

Dress  with  French  Dressing. 

Egg  Salad 

Cook  1  egg  hard.  Cut  into  rings;  arrange  on  lettuce  leaf; 
dress  with  Cream  Dressing. 


DIABETES  MELLITUS  '     371 

Tomato  Aspic 

1  cup  canned  tomatoes  J  cup  water 

J  cup  celery  (hearts)  *  J  cup  vinegar 

1  tsp.  celery  seed  3-4  cloves 
J  small  onion                                   ^  bay  leaf 

2  tsp.  granulated  gelatine,  soaked  in  tbs.  water 

Boil  all  ingredients  (except  gelatine  and  celery  hearts)  20  minutes. 
Measure.  Add  hot  water  or  tomato  juice  to  make  one  cup ;  add 
gelatine ;  allow  to  cool ;  cut  celery  fine,  place  in  mold ;  pour  in 
the  tomato  aspic  and  allow  to  jelly  in  a  cold  place. 

Bread  Substitutes 

Bran  Biscuits,  or  Muffins 

1  cup  washed  bran  1  tbs.  melted  butter 

1  tsp.  baking  powder  2  tbs.  cream 

1  egg  J  tsp.  salt 

Tie  bran  in  cheesecloth  bag  and  attach  to  cold  water  faucet ; 
allow  water  to  pass  through  bran,  removing  starch  by  squeezing 
the  water  through ;  using  dry.  Beat  egg  separately ;  add  cream ; 
mix  with  bran,  add  melted  butter,  salt,  and  baking  powder.  Grease 
muffin  rings  and  pour  in  the  mixture.     Bake  in  moderate  oven. 

Dl\betes  Muffins  ^^ 

(The  Equivalent  of  an  Egg) 

Recipe  for  Hepco  Cakes,  so  arranged  that  one  cake  is  equiva- 
lent to  an  egg : 

140  gm.  Hepco  flour  Protein  60  Fat  29 

2  eggs  Protein  12  Fat  12 
60  c.c.  40%  cream  Protein  2  Fat  24 
10  gm.  butter                                                                     Fat    9 

Make  twelve  cakes;  each  cake  contains  6  grams  of  protein, 
6  grams  of  fat,  and  approximately  75  calories. 

"  "  The  Treatment  of  Diabetes  Mellitus,"  p.  531,  by  Joslin. 


372     '  DIETETICS  FOR  NURSES 

Lister  Muffins 
So  arranged  that  each  muffin  is  equivalent  to  one  egg : 

60  gm.  Lister  flour  (one  box)  Protein  42  Fat    0 

1  egg  Protein    6  Fat    6 

45  c.c.  40%  cream  Protein    2  Fat  18 

30  gm.  butter  Fat  25 

Make  17  muffins ;  each  muffin  contains  6  grams  protein,  6  grams 
fat. 

Bran  Biscuits  for  Constipation 

By  F.  M.  Allen 

60  gm.  bran  6  gm.  powdered  agar-agar 

J  tsp.  salt  100  c.c.  (I  glass)  cold  water 

Tie  bran  in  cheesecloth  and  wash  under  tap  until  water  is  clear. 
Bring  agar-agar  and  water  (100  c.c.)  to  boiling  point.  Add 
washed  bran  and  salt  and  agar-agar  solution  (hot).  Mold  into 
ten  cakes ;  place  on  oiled  paper  and  let  stand  |  hour,  then  when 
firm  and  cool,  bake  in  moderate  oven  30  to  40  minutes.  •  The  bran 
muffins  are  more  palatable  if  butter  and  eggs  are  added.  This 
may  be  done,  provided  the  patient  allows  for  them  in  the  diet. 

Casoid  Flour  and  Bran  Muffins 

1  oz.  (30  gm.)  Casoid  flour  1  egg  white  (whole  egg  may  be 
1  level  tbs.  (15  gm.)  butter  substituted  for  1  egg  white) 

1  oz.  (30  c.c.)  40%  cream  1|  tsp.  baking  powder 

I  tsp.  salt  1  cup  washed  bran 

Total  food  value :  protein,  18  grams ;  fat,  24  grams ;  carbohy- 
drates, 1  gram ;   calories,  300  grams. 

One  muffin :  protein,  3  grams ;  fat,  4  grams ;  carbohydrates 
and  calories,  50. 

The  flours  and  meals  used  in  this  recipe  are  prepared  by  Cutlard, 
Stewart  &  Walt,  Ltd.,  London  (Casoid  Flour).     Theo.  Metcalf  & 


DIABETES  MELLITUS  373 

Co.,  Boston  (soya  bean  meal).     Lister  Brothers,  Andover,  Mass. 
(Lister  Diabetic  Flour). 

Lister  Flour  and  Bran  Muffins,  or  Biscuits 


1  cup  washed  bran 

1  tbs.  butter 

30  gm.  Lister  flour 

legg 

1  tsp.  baking  powder 

f  tsp.  salt 

2tbs. 

40% 

cream 

Sufficient  water  to  make  a  drop  batter  (about  J  cup) 

Squeeze  all  the  water  from  the  bran,  then  add  flour  and  melted 
butter,  salt,  well-beaten  egg  yolk  and  cream.  Whip  egg  white 
stiff  and  fold  into  mixture.  Add  baking  powder  and  enough  water 
to  make  thick  batter.  Use  less  water  if  biscuits  instead  of  muffins 
are  desired,  and  knead  into  a  dough.  Roll  out  into  a  sheet  one- 
half  inch  thick  and  cut  with  biscuit  cutter. 

After  making  muffin  batter,  grease  muffin  rings  with  melted 
lard,  and  pour  half  full  of  above  mixture.  Bake  in  moderate  oven 
about  20  or  30  minutes. 

Soya  Meal  and  Bran  Muffins  ^ 

1  oz.  (30  gm.)  soya  meal  1  cup  washed  bran 

1  level  tbs.  (15  gm.)  butter  1  egg  white  (one  whole  egg  may 

1  oz.  (30  c.c.)  40%  cream  be    substituted    for    one    egg 

I  tsp.  salt  white) 

Ij  tsp.  baking  powder 

Mix  soya  meal,  salt,  and  baking  powder.  Add  to  washed  bran  ; 
add  melted  butter  and  cream.  Beat  egg  white  and  fold  into  mix- 
ture ;  add  enough  water  to  make  thick  drop  batter.  Bake  in  six 
well-greased  muffin  tins  until  golden  brown  from  15  to  25  minutes. 

Total  food  value:  protein,  11  grams;  fat,  27  grams;  carbo- 
hydrates, 2  grams ;  calories,  304 ;  one  muffin,  2  grams ;  fat,  4.5 
grams;   carbohydrates,  trace;  calories,  50. 

"  "Starvation  Treatment  of  Diabetes,"  p.  43,  by  Hill  and  Eckman. 


374  DIETETICS  FOR  NURSES 

Almond  Biscuits 

1  cup  almond  meal  1  grain  (or  less)  saccharine,  dis- 

1  oz.  cream  solved  in  1  tsp.  of  water 

1  egg  1|  tsp.  baking  powder 

3-4  drops  vanilla 

Beat  egg  yolk  until  light,  add  cream  and  saccharine ;  stir  this 
into  almond  meal.  Fold  in  the  stiffly  beaten  white.  Drop  on  a 
greased  paper  and  bake  until  golden  brown  in  a  moderate  oven. 

Almond  meal  or  flour  is  prepared  as  follows : 

Blanch  1  pound  of  almonds ;  dry  and  pass  through  grinder,  or 
pound  in  mortar  until  powdered.  Place  in  a  muslin  bag  and  im- 
merse in  a  pan  of  water  acidulated  with  vinegar  to  remove  sugar  ; 
allow  to  stand  15  minutes.  Squeeze  dry  and  place  in  a  warm  (not 
hot)  oven  to  remove  all  moisture.  Grind  or  pound  once  more. 
Almond  flour  does  not  keep  well ;  it  must  be  made  in  small  quan- 
tities and  kept  in  a  glass  jar  in  a  cool  place. 

CocoANUT  Flour 

Grate  cocoanut  and  treat  as  almonds  to  remove  sugar;  dry 
thoroughly  and  grind  or  pound  to  fine  meal. 

Cocoanut  Biscuits 

1  cup  cocoanut  Ij  tsp.  baking  powder 

1  egg  white  (or  whole  egg  if  desired)  ^  grain  saccharine 

(A  biscuit  maybe  made  without  saccharine  for  bread  substitute.) 

Spanish  Cream 

5  tbs.  coffee,  or  1  tbs.  cold  water 

Infusion  of  cocoa  nibs  30  c.c.  (1  oz.)  40%  cream 

1  tsp.  gelatine  1  egg 

Saccharine  to  sweeten 

Pour  coffee,  or  cocoa  infusion,  into  a  double  boiler,  beat  egg 
yolk  and  saccharine  dissolved  in  1  tsp.  of  water,  and  stir  into  hot 


DIABETES  MELLITUS  375 

coffee.  Cook  gently  until  mixture  coats  the  spoon  (raw  flavor  of 
egg  has  disappeared) ;  add  gelatine  and  mix  thoroughly.  Whip 
cream  and  egg  white.     Place  on  ice  to  set. 

Lister  Cream  Puff 

This  is  made  by  pouring  30  grams  of  soft  custard  (diabetic)  over 
1  Lister  biscuit. 

Custard 

i  cup  cream  1  egg 

J  grain  saccharine  3-4  drops  vanilla  or  almond  extract 

Beat  egg  until  it  is  well  broken  up,  but  not  light ;  stir  into  the 
cream;  dissolve  saccharine  in  teaspoonful  of  water  and  add  to 
mixture.  If  custard  is  to  be  baked,  pour  into  molds  and  place 
upon  a  rack,  or  on  a  folded  cloth  in  a  pan  half  filled  with  hot  water ; 
bake  in  moderate  oven  until  firm  in  center. 

If  soft  custard  is  desired,  pour  mixture  into  double  boiler  and 
cook  gently  until  mixture  coats  the  spoon  and  the  raw  egg  flavor 
has  disappeared. 

Snow  Pudding 

Make  ^  cup  gelatine,  as  directed  below. 
Whip  in  1  egg  white. 

When  gelatine  is  half  congealed,  mold  and  set  on  ice. 
When  ready  to  serve,  unmold  and  serve  with  custard,  or  1  tbs. 
whipped  cream. 

Jellies 

1  tbs.  cold  water  to  2  tsp.  granulated  gelatine  is  used  in  making 
the  following  jellies : 

Lemon 

16.6  calories 

•g-  cup  boiling  water  ^  lemon  or  2  tbs.  (juice  and  ^ 

T  to  I-  saccharine  tablet  dis-  rind  sliced  thin) 

solved  in  1  tbs.  water 


376  DIETETICS  FOR  NURSES 

Orange 

54  calories 

i  cup  boiling  water  i-  to  |^  saccharine  tablet   dis- 

i  tbs.  lemon  juice  solved  in  1  tbs.  water 

^  cup  orange  juice  2  drops  orange  extract 

Wine 

40.8  calories 

^  cup  boiling  water  l-inch  piece  of  cinnamon 

3  tbs.  sherry  wine  i  to  ^  saccharine  tablet  dissolved 

1  tsp.  lemon  juice  and  the  yellow  in  1  tbs.  water 
rind  from  i  lemon 

Method  for  Fruit  Jellies 

Soak  gelatine  in  cold  water  about  2  or  3  minutes,  then  pour  over 
it  the  boiling  liquid ;  add  saccharine  and  fruit  juice,  strain  through 
cloth  into  wet  molds.  Set  in  cold  place  to  stiffen ;  when  firm, 
unmold.  Serve  with  whipped  cream,  or  pour  liquid  into  baskets 
made  from  orange  or  grapefruit,  hollowed  out  and  the  edges 
scalloped,  or  pour  into  shallow  pans,  and  cut  in  |-inch  blocks  when 
firm  and  serve  on  a  bed  of  whipped  cream. 

Wine  Jelly 

Put  water,  wine,  lemon  juice  and  peel,  cinnamon,  and  saccharine 
into  a  saucepan,  allow  to  boil  5  minutes,  pour  over  gelatine  (which 
has  been  soaked  in  cold  water).  If  the  jelly  looks  cloudy,  return 
to  saucepan,  and  add  ^  egg  white  beaten  stiff ;  allow  to  boil  1 
minute,  stirring  constantly,  and  strain  into  mold.  Serve  with 
whipped  cream. 

Ices 

Lemon 

30  calories 

i  cup  water  }  to  ^  saccharine  tablet 

Fruit  juice,  1  lemon  1  egg  white 


DIABETES  MELLITUS  377 

Orange 

75.5  calories 

\  cup  water  J  lemon 

1  large  or  2  small  oranges       i  to  ^  saccharine  tablet 
1  egg  white 

Sweeten  fruit  juice  with  saccharine  instead  of  sugar.  Clip  egg 
white  with  scissors,  or  beat  with  Dover  egg  beater,  add  mixture 
and  freeze. 

Ice  Cream 

(1)  Use  recipe  for  soft  custard,  freezing  after  the  custard  has 
become  thoroughly  cold. 

(2)  \  cup  cream  J  grain  saccharine  or  enough 
1  tbs.  chopped  nuts  to    sweeten,    dissolved    in 

1  tsp.  water 
3-4  drops  vanilla,  orange,  or  almond  extract 

• 
Whip  cream,  add  saccharine  and  nuts.    Pour  into  a  small  J-pound 
baking  powder  can,  seal  the  edges  of  mold  or  can  with  a  thin  strip 
of  buttered  muslin.     Pack  in  equal  parts  of  salt  and  ice  for  two 
hours. 

Irish  Moss  Pudding 

Carefully  pick  over  and  wash  through  several  waters  1  tbs. 
Irish  moss.  Place  in  double  boiler  with  \  cup  of  water  and  3  tbs. 
40%  cream  and  \  grain  saccharine.  Cook  until  mixture  thickens 
when  dropped  upon  a  cold  saucer.  Pour  over  1  stiffly  beaten 
egg  white;  add  3-4  drops  of  vanilla  extract.  Mold  and  set 
on  ice. 

Irish  moss  may  be  used  as  a  substitute  for  gelatine.  The  carbo- 
hydrates in  this  substance  are  not  believed  to  be  utilized  for  the 
manufacture  of  glucose  in  the  human  body. 


378  DIETETICS  FOR  NURSES  •  : 

Nut  Charlotte  - 

I 

60  c.c.  (2  oz.)  40%  cream  Saccharine  to  sweeten  i 

30  gm.  chopped  walnuts  3-4  drops  vanilla  \ 

Whip  cream  stiff ;  add  saccharine,  nuts,  and  vanilla.  ' 

I 
1  tbs.  sherry  wine  and  1  tsp.  gelatine  soaked  in  1  tbs.  cold 
water  and  melted  over  hot  water  may  be  substituted  for  vanilla  ■ 

to  vary  the  above  recipe. 

1 

I 
Orange  Charlotte  \ 

75  c.c.  (5  tbs.)  orange  juice  1  tsp.  gelatine 

45  c.c.  (3  tbs.)  40%  cream  1  tbs.  cold  water 

J  egg  white  Saccharine  to  sweeten 

Soak  gelatine  in  cold  water ;    dissolve  over  hot  water,  add  to  J 

orange  juice;  add  saccharine;  set  aside  until  it  begins  to  jelly.  \ 

Whip  cream  and  add  to  partially  jellied  orange  juice ;  fold  in  the  ] 

stiffly  beaten  egg  white ;  mold.     Serve  30  grams.  j 


CHAPTER   XXIII 
DISEASES  OF  THE  LIVER 

Much  of  the  so-called  biliousness  from  which  the  human  family 
is  so  prone  to  suffer  is  nothing  more  or  less  than  one  of  Nature's 
danger  signals  by  means  of  which  man  may  understand  that 
some  part  of  the  delicate  organism  called  the  human  body  is  being 
overworked.  Close  investigation  of  these  conditions  has  proved 
that  it  is  the  liver  which  has  been  overtaxed,  in  many  cases  to  such 
an  extent  that  in  a  measure  it  slows  down,  as  any  overtaxed 
machine  will  do,  and  has  become  clogged  with  material  which, 
owing  to  its  condition,  it  is  not  able  to  prepare  properly  and  send 
out  on  time. 

Work  of  the  Liver.  —  When  one  considers  the  vast  amount  of 
work  performed  by  this  organ,  one  marvels  that  so  little  trouble  is 
manifested.  In  another  part  of  this  text  the  functions  of  the  liver 
were  defined.  It  was  found  to  be  the  largest  secretory  organ  in 
the  body,  producing  a  constant  supply  of  bile  by  means  of  which 
the  fats  were  dissolved  and  the  digestion  and  absorption  of  the 
other  food  materials  facilitated.  We  likewise  found  that  the 
greater  part  of  the  fuel  foods  was  transformed  within  this  organ 
into  available  energy,  either  for  immediate  or  future  use. 

As  a  Detoxifying  Agent.  —  To  the  liver  must  also  be  credited 
the  detoxifying  of  the  various  poisons  produced  within  the  body 
during  the  process  of  metabolism  or  brought  in  by  way  of  food. 
Too  much  cannot  be  said  as  to  the  value  of  the  liver  in  this  respect, 
the  importance  of  which  is  made  known  as  soon  as  anything 
happens  to  the  organ  to  put  it  even  temporarily  out  of  commission. 

Causes  of  Liver  Disorders.  —  Is  it  any  wonder,  then,  that  with 
such  abuses  as  overeating  and  drinking,  especially  of  those 
foods  rich  in  fats  and  carbohydrates  which  depend  upon  the  liver 

379 


380  DIETETICS  FOR  NURSES 

for  their  availability  in  the  body,  Nature  cries  aloud  for  help  and 
for  the  comparative  rest  of  this,  her  largest  organ  ? 

The  taking  of  alcohol  in  excess  has  been  found  to  bring  about 
tissue  changes  in  the  liver.  Hence  it  must  be  avoided  by  in- 
dividuals with  a  tendency  to  biliousness  or  to  any  disease  in  which 
the  liver  is  involved. 

The  Bowels.  —  The  bowels  are  as  a  rule  constipated,  and  one 
of  the  first  means  of  relief  is  the  overcoming  of  this  condition. 
The  method  of  doing  this  depends  upon  the  individual,  and  the 
treatment  must  be  decided  on  by  the  physician. 

Dietetic  Treatment.  —  The  dietetic  treatment  consists  in 
abstaining  from  food  or  reducing  the  amount  to  a  minimum  while 
the  attack  lasts  and  while  the  intestines  are  being  thoroughly 
emptied.  All  stagnant  material  which  has  clogged  the  bowels 
and  which  has  been  subjected  to  the  activities  of  putrefactive  bac- 
teria must  be  gotten  rid  of.  The  diet  must  be  especially  low  in 
fat.  Oyster  or  clam  broth,  soft-cooked  eggs,  toast,  cereal,  or 
rice,  with  a  little  milk  instead  of  cream  and  very  little  sugar, 
tea,  and  baked  apple  or  stewed  prunes  are  given. 

Convalescent  Diet.  —  After  the  attack  the  diet  may  be  gradually 
increased  until  it  is  again  normal.  Moderation  must  be  observed 
in  the  amount  of  food  eaten ;  no  highly  seasoned  or  spiced  foods, 
pickles,  or  condiments,  such  as  peppers,  mustard,  or  horseradish, 
should  be  taken.  Salads  should  be  dressed  without  oil.  Lean 
beef,  lamb  chops,  fish,  chicken,  sweetbreads,  quail,  squab,  eggs 
(except  fried  or  hard  cooked),  green  vegetables  (except  radishes, 
onions,  watercress,  and  celery)  in  abundance,  a  small  amount  of 
potato,  rice,  or  tapioca,  fresh  and  cooked  fruit  with  little,  if  any 
sugar,  junket,  custards,  fruit  jellies,  weak  tea  and  coffee  should 
constitute  the  diet.  Certain  individuals  find  that  milk  increases 
the  tendency  to  constipation ;  this  is  probably  due  to  the  small 
amount  taken;  large  quantities  do  not  as  a  rule  produce  this 
effect.  Buttermilk,  koumiss,  and  modified  milk  are  advised  in 
severe  cases. 

Diet  for  Constipation.  —  Individuals  inclined  to  biliousness 
should  endeavor  to  overcome  the  constipation  which  is  one  of  the 


DISEASES  OF  THE  LIVER                     381  \ 

.    i 
I 

most  prominent  features.     This  is  done  by  proper  diet  more  I 

successfully   than  by  drugs  (cathartics) :   bran  bread,  vegetable  \ 
soup,  fresh  fruit,  stewed  fruit,  fruit  beverages,  plenty  of  water. 

The  following  menus  are  suggested  :  \ 

Breakfast  —  Stewed  prunes  [ 

Oatmeal  with  milk  (no  sugar)  I 

Weak  tea  or  coffee  i 

Toast  (milk  toast  or  dry  toast)  ' 

Lunch  —  Tomato  soup  i 

1  small  baked  potato  * 
1  lean  lamb  chop  (broiled)  or  a  poached  egg  on 

toast  : 

Cup  of  weak  tea  ' 

Dinner  —  Vegetable  soup  j 

1  slice  of  lean,  rare  beef  (cut  from  the  inside  of  ] 

the  roast)  \ 

Spinach  i 

Rice  J 

Lettuce  and  tomato  salad  l 

Lemon  jelly  I 

Breakfast  —  Grapefruit                                                               ^  j 

Hominy  with  milk  \ 

Poached  egg  on  toast  I 

Weak  coffee  (milk  and  little  sugar)  ■ 

Lunch  —  Cream  of  green  pea  soup  i 

Tomato  jelly  ; 

Broiled  sweetbreads  | 

Weak  tea  j 

Toast  ■ 

Dinner  —  Small  portion  of  lean  lamb  or  chicken 
Boiled  or  mashed  potatoes 

String  beans  ] 

Sliced  tomatoes  : 

Prune  whip  ; 


382  DIETETICS  FOR  NURSES 

Advice  to  Patient.  —  The  above  menus  are  merely  suggested. 
The  diet  may  be  selected  from  the  list  of  foods  already  mentioned. 
The  patient  must  be  warned  against  overeating  and  drinking. 
Pastry,  rich  cakes  and  puddings,  confectionery,  gravies,  etc., 
must  be  avoided.  In  certain  individuals  beer  will  induce  a 
bilious  attack.     By  them  it  should  be  avoided. 

CIRRHOSIS   OF   THE   LIVER 

The  cause  of  this  disease  and  the  stage  in  which  it  exists  must 
determine  the  treatment  necessary.  However,  it  matters  not  what 
produced  the  disease,  whether  it  is  the  result  of  alcoholism,  syphilis, 
etc.,  the  diet  plays  an  important  role  in  its  cure. 

The  Diet.  —  The  diet  in  this  disease,  as  in  any  other,  must  be 
determined  by  the  condition  of  the  patient.  Unfortunately,  many 
patients  do  not  know  of  their  condition  until  the  disease  is  well 
advanced  and  symptoms  of  obstruction  are  prominent.  A  study 
of  these  must  be  made  before  the  diet  can  be  formulated.  When 
the  symptoms  are  mainly  those  arising  from  disturbed  digestion 
of  the  stomach  and  intestines,  without  kidney  or  heart  com- 
plication, the  diet  for  chronic  gastritis  is  used. 

Restricting  the  Fluids.  —  When  the  heart  is  involved,  it  is 
sometimes  found  necessary  to  restrict  the  fluids  (dry  diet)  to  1 
quart  (about  1000  c.c.)  per  day.  The  Karell  cure  has  been  used 
advantageously  in  many  of  these  cases.  In  cases  where  the 
kidneys  are  involved,  the  diet  will  depend  upon  the  condition  of 
these  organs. 

Restricting  the  Diet.  —  The  diet  in  any  case  must  be  restricted. 
Individuals  wdth  a  tendency  to  cirrhosis  and  those  coming  of  a 
family  in  which  liver  diseases  are  frequent  should  be  especially 
warned  about  the  dangers  of  overeating  and  drinking.  Alcohol 
should  be  avoided  especially  by  such  individuals.  They  should 
keep  their  diet  simple  in  character  and  moderate  in  amounts. 

Avoidable  Foods.  —  All  foods,  such  as  condiments  and  spices, 
meat  extracts,  the  outside  browned  portions  of  roasted  meat, 
alcoholic  beverages,  which  exert  a  stimulating  or  irritating  effect 
upon  the  liver,  should  be  studiously  avoided  and  the  fats  and  carbo- 


DISEASES  OF  THE  LIVER  383 

hydrates  restricted,  since,  as  it  has  already  been  demonstrated, 
it  is  upon  the  liver  that  the  body  depends  for  the  preparation  of 
these  substances  for  their  utilization.  When,  for  example,  the 
flow  of  bile  is  lessened,  an  incomplete  emulsification  of  the  fats 
exists  and  the  fatty  acids  which  are  highly  acid  in  character 
cannot  be  efficiently  dissolved  or  neutralized,  or  when  the  liver 
is  diseased  and  for  this  reason  the  conversion  of  glycogen  into 
glucose  is  interfered  with,  the  utilization  of  the  carbohydrate 
foods  is  thus  impaired. 

GALLSTONES 

Factors  Influencing  Their  Formation.  —  According  to  Freiden- 
wald  and  Ruhrah^  the  two  factors  that  in  all  probability  exert 
the  most  influence  on  the  formation  of  gallstones  are  the  stasis  of 
bile  and  the  inflammation  of  the  bile  passages  and  gall  bladder. 

Dietary  Rules.  —  There  are  certain  dietary  rules  which  should 
be  observed  by  all  persons  who  have  had  gallstone  attacks.  These 
are  (1)  to  prevent  stasis  of  bile,  (2)  to  avoid  fats.  Everything 
should  be  done  to  prevent  the  formation  of  the  stones,  and  this 
can  only  be  accomplished  by  observing  these  rules.  The  flow  of 
bile  must  be  free;  this  is  encouraged  by  keeping  the  intestinal 
tract  in  good  condition. 

Stimulating  Peristalsis.  —  Peristalsis  must  not  be  allowed  to 
become  sluggish,  for  it  is  only  during  the  process  of  digestion  when 
the  food  mass  passes  along  the  intestinal  canal  that  there  is  an 
ejection  of  bile  into  the  intestines.  When  the  passage  is  abnor- 
mally slow  the  bile  is  in  a  measure  dammed  back  with  a  formation 
of  gallstones  as  a  result.  The  restriction  of  the  fats  has  already 
been  discussed  in  another  part  of  the  chapter.  It  has  been  demon- 
strated that  these  substances  have  a  chemical  influence  upon  the 
formation  of  gallstones  as  well  as  upon  the  intestinal  stasis  which 
leads  to  their  formation. 

Dietetic  Treatment.  —  Hence  the  diet  should  be  so  directed  as 
to  (1)  increase  the  flow  of  bile,  and  (2)  to  avoid  all  foods  that  are 
liable  to  cause  indigestion  which  may  bring  about  putrefaction 

i  "Diet  in  Health  and  Disease,"  p.  399,  by  Freidenwald  and  Ruhrah. 


384  DIETETICS  FOR  NURSES 

in  the  intestinal  tract  and  a  consequent  irritation  and  inflammation 
of  the  bile  passages  and  gall  bladder. 

The  meals  should  be  regular  and  an  abundant  diet  advised  to 
increase  the  flow  of  bile  and  stimulate  peristalsis  in  the  intestines. 

Exercise.  —  Exercise  is  especially  recommended.  Horseback 
riding,  swimming,  rowing,  golf,  and  tennis  are  especially  valuable 
in  forcing  the  bile  from  the  gall  bladder  and  liver. 

The  Clothing.  —  The  clothing  should  be  loose  enough  to  be 
perfectly  comfortable.  Certain  cases  of  gallstone  attacks  in 
women  have  been  said  to  have  been  traced  to  tight  lacing,  which 
interfered  with  the  normal  flow  of  the  bile. 

The  Bowels.  —  Constipation  should  be  avoided,  and  the  diet 
should  be  directed  with  this  point  in  view.  The  meals  must  be 
frequent,  ranging  from  four  to  six  a  day.  In  this  way  only  is 
the  flow  of  bile  encouraged.  The  breakfast  should  be  ample 
in  order  to  utilize  the  bile  secreted  in  the  night  season.  With  all 
this,  care  must  be  observed  not  to  give  more  food  than  can  be 
adequately  handled  by  the  digestive  apparatus,  since  food  which 
is  not  digested  becomes  a  prey  to  the  actions  of  the  putrefactive 
bacteria  which  infest  it,  and  the  toxic  substance  thus  formed 
produces  the  very  result  which  all  of  our  efforts  are  directed 
to  prevent. 

Available  Foods.  —  The  following  foods  low  in  fats  may  be 
used  in  formulating  the  diet : 

Soups:  Meat  broth  (made  from  lean  meat)  from  which  all 
the  fat  has  been  removed. 

Meats:  Lean  beef,  lamb,  chicken,  squab,  quail,  lean  fish  (in 
small  quantities  and  not  too  frequently). 

Green  vegetables :  Except  peas  and  carrots ;  beets  and  tur- 
nips may  be  taken  sparingly. 

Fruits :  Oranges,  lemons,  grapefruit,  and  unsweetened  stewed 
fruit. 

Cereals :  Wheat  cereals,  oatmeal,  rice,  and  tapioca  in  modera- 
tion. 

Bread:  Whole  wheat,  white,  rye,  and  graham  bread,  toast, 
and  crackers. 


DISEASES  OF  THE  LIVER  385 

Fluids:  Weak  tea  and  coffee  (without  cream,  and  a  little 
sugar),  orange  and  lemonade,  mineral  waters,  water,  skimmed 
milk,  whey. 

Eggs:  (except  hard-cooked  or  fried). 

Desserts :  Fruit  gelatine,  fruit  whips,  raw  or  stewed  fruit. 

Avoid  the  following  foods:  Fats,  oils,  mutton,  liver,  brains, 
sardines,  and  caviar,  oily  fish,  rich  gravies  and  sauces,  sweet 
fruit,  peas,  carrots,  condiments  and  spices,  pastry  and  confection- 
ery, pickles,  alcoholic  beverages.  Restrict  carbohydrates,  yolks 
of  eggs,  milk  (cream  must  be  skimmed  off  if  too  rich). 


DAILY  DIET  SHEETS 
I 

Breakfast  —  Baked  apple  with  milk 

Cream  of  wheat  with  milk 
Weak  coffee  or  tea 
Dry  toast 

11:30  a.m. — 6  oz.  orange  juice,  1  egg  white 

Dinner  —  Beef  broth  (well  skimmed)  with  crackers 
Rice 

Stewed  pears 
Weak  tea 
Toast  or  rolls 

3  :  30  P.M.  —  Albumenized  fruit  juice  with  crackers 

Supper  —  Wheatena  with  milk 
Milk  toast 
Stewed  prunes 
Toast  and  tea 

9  P.M.  —  Well-skimmed  chicken  broth  with  crackers. 

2c 


386  DIETETICS  FOR  NURSES 

II 

Breakfast  —  Stewed  apples  with  milk 
Milk  toast 
Coffee  without  cream 

10:30  a.m. — Well-skimmed  broth  with  crackers 

Dinner  —  Tomato  bouillon  with  crackers 
Baked  potato  —  1  small  potato 
Puree  of  spinach 
Orange  gelatine 
Toast 

3  P.M.  — Albumenized  lemonade 

Supper — Oatmeal  or  cream  of  wheat  with  milk 
Toast 
Tea 
Stewed  fruit 

9  P.M.  —  Well-skimmed  broth  with  crackers 

ni 

Breakfast — Grapefruit 

Oatmeal  with  milk 

Toast 

Weak  coffee 

10:30  a.m. — Orangeade  with  graham  crackers 

Dinner — Cream  of  spinach  soup  (skimmed  milk) 
Small  piece  of  the  breast  of  chicken 
Mashed  or  boiled  potatoes 
Asparagus  on  toast 
Sliced  oranges 

3  :  30  P.M.  — Well-skimmed  broth  with  crackers 


DISEASES  OF  THE  LIVER  387 

Supper — Farina  or  cream  of  wheat  or  wheatena,  with  milk 
Baked  potato 
Baked  apple  with  milk 
Toast  and  tea 

9  P.M.  — Albumenized  orange  juice 

IV 

Breakfast — Sliced  oranges 
Oatmeal 
Toast 
Coffee 


10 :  30  a.m. — Beef  gruel,  6  oz.  ; 

Dinner — Cream  of  asparagus  soup,  skimmed  milk  ] 

Thin  slice  of  roast  beef  or  whitefish  ] 

Rice  or  potatoes  i 

Tender  string  beans  I 

Fruit  '                           I 

Toast  \ 

Buttermilk  \ 

3:30  p.m. — Orangeade  1 

! 

Supper — Stewed  fruit  with  puffed  wheat  or  rice  ' 

Milk  toast  •   ; 

Tea  1 

1 

9  p.m.  — Broth  i 


summary 

Functions  of  Liver.  —  To  transform  fuel  foods  into  available 
energy;  to  detoxify  those  poisonous  substances  produced  as  the 
result  of  metabolism  of  body  tissue  or  brought  in  in  food,  and 
to  select  those  available  for  use ;  to  secrete  bile. 


388  DIETETICS  FOR  NURSES 

Factors  Influencing  Disorder  of  Liver.  —  Errors  in  diet :  (a) 
overeating;  (6)  excessive  drinking;  and  (c)  unbalanced  diet, 
especially  as  regards  the  amount  of  fats  and  carbohydrates  in  the 
diet. 

The  Bowels,  in  most  of  the  disturbances  affecting  the  liver, 
become  constipated,  thus  causing  much  additional  work  on  the 
part  of  the  liver  in  handling  the  products  produced  as  the  result 
of  putrefactive  bacteria  upon  the  accumulated  mass  in  the  colon. 

Tissue  Changes  in  the  liver  have  been  caused  by  the  taking 
of  alcohol,  which  should  therefore  be  avoided  by  all  individuals 
having  any  disease  involving  the  liver  and  by  those  with  a  pre- 
disposition to  liyer  disturbances. 

Exercise  and  Lack  of  Exercise  are  potent  factors  in  the 
treatment  of  conditions  involving  the  liver.  First,  because  the 
liver  requires  exercise  to  enable  it  to  empty  itself  more  completely 
and  assure  a  free  flow  of  bile ;  second,  because  exercise  directly 
affects  the  energy  output  of  the  body,  causing  an  increased  rate  of 
metabolism  and  a  better  utilization  of  the  food  ingested.  Lack 
of  exercise  acts  in  exactly  the  opposite  direction,  and  it  has  been 
found  that  with  the  majority  of  patients  suffering  from  diseases 
of  the  liver  too  little  exercise  and  too  much  food  are  at  the  bottom 
of  the  trouble. 

Dietetic  Treatment  in  the  majority  of  diseases  affecting  the 
liver  is  much  the  same.  The  keynote  in  each  is  a  balanced  diet. 
Constant  overeating  and  excessive  drinking  have  proved  the 
foundation  of  the  majority  of  such  diseases,  especially  of  the 
biHous  type,  while  an  excess  of  fat  and  carbohydrates  in  the  diet 
lead  to  the  more  serious  disorders. 

Biliousness  requires  abstinence  from  food  for  a  short  period 
and  a  cleansing  of  the  entire  gastro-intestinal  tract,  the  meas- 
ures being  directed  by  the  physician.  After  the  bilious  symp- 
toms have  subsided,  a  simple,  well-regulated  diet  should  be 
established,  in  which  no  rich  foods  of  any  sort  are  allowed.  All 
condiments  and  spices  which  have  an  astringent  effect  upon  the 
bowels  are  strictly  prohibited,  and  alcoholic  beverages  had  best 
be  eliminated  from  the  diet. 


DISEASES  OF  THE  LIVER  389 

Cirrhosis  of  the  liver  is  apt  to  be  insidious  in  its  development, 
taking  a  firm  hold  before  the  character  of  the  disorder  is  discovered. 
Dietetic  treatment  of  this  disturbance  is  most  important  and  should 
be  directed  toward  overcoming  not  only  the  liver  symptoms  but 
other  symptoms  as  well. 

Gastro-mtestinal  Disturbances,  manifested  in  cirrhosis  of  the 
liver,  are  treated  by  the  diet  used  in  chronic  gastritis  (see  p.  230). 

Heart  Symptoms  sometimes  occur  during  the  course  of  the 
disease  and  require  especial  attention  to  the  diet.  The  fluids  at 
times  must  be  restricted,  in  which  case  a  modification  of  the 
Karell  Cure  will  prove  valuable  (see  p.  310). 

Kidney  Complications  develop  in  a  certain  percentage  of  cases, 
and  it  then  becomes  necessary  to  institute  one  of  the  various 
diets  devised  to  meet  the  needs  of  those  special  conditions  (see 
Chapter  XX). 

Restricting  the  Diet  will  be  found  to  be  necessary  for  those 
individuals  showing  a  tendency  to  cirrhosis,  also  for  those  in 
whose  family  diseases  of  the  liver  are  of  frequent  occurrence. 
Such  individuals  should  be  warned  of  the  dangers  arising  from  over- 
indulgence in  food  or  alcoholic  beverages. 

Prohibited  Foods  are  those  which  by  reason  of  their  astrin- 
gent qualities  favor  the  development  of  constipation,  such  as 
condiments  and  spices ;  those  foods  which  exert  a  stimulating  and 
irritating  effect  upon  the  liver  and  bile  passages,  such  as  alcohol, 
malt  extractives,  etc. ;  and  fats  and  carbohydrates  in  excessive 
quantities,  on  account  of  the  extra  amount  of  work  required  of  the 
liver  in  order  to  make  them  available  in  the  body. 

Gallstones  develop  as  the  result  of  inflammation  or  clogging 
of  the  bile  passages. 

Treatment  is  dietetic  in  character  and  is  directed  toward  re- 
lieving or  preventing  inflammation  in  the  bile  passages,  also  in 
stimulating  the  flow  of  bile  in  order  that  it  may  not  become 
sluggish  and  thus  give  rise  to  the  development  of  the  gallstones. 

The  Fats,  therefore,  must  be  restricted  in  the  diet,  as  they, 
more  than  any  of  the  other  food  constituents,  favor  the  above 
conditions. 


390  DIETETICS  FOR  NURSES 

Peristalsis  in  the  intestinal  tract  must  be  stimulated  to 
facilitate  a  free  flow  of  bile,  which  will  not  occur  where  the  move- 
ments are  sluggish.  Stasis  of  the  bile  must  be  prevented  or  stones 
will  be  apt  to  form. 

Dietetic  Treatment  for  gallstones  is  therefore  directed  to 
increase  the  flow  of  bile  and  to  avoid  the  inflammation  of  the  gall 
bladder  and  bile  passages  which  may  result  from  the  product 
of  intestinal  putrefaction. 

The  Diet  consists  of  foods  simple  in  character,  low  in  fats, 
but  abundant  in  quantity,  in  order  to  prevent  constipation.  It 
must  be  selected  carefully  that  digestional  disturbances  may  not 
develop. 

The  Meals  should  be  frequent,  from  four  to  six  a  day,  in 
order  to  encourage  a  free  flow  of  bile. 

Breakfast  should  be  ample  in  order  that  the  bile  secreted 
and  accumulated  during  the  night  may  be  utilized  as  soon  as 
possible. 

Constipation  must  be  avoided,  and  the  foods  particularly 
adapted  to  prevent  or  overcome  this  condition  should  have  a 
prominent  place  in  the  diet.  Any  accumulation  of  unabsorbed 
food  in  the  lower  intestines  becomes  a  breeding  ground  for  putre- 
factive bacteria,  the  product  of  whose  activity  imposes  a  serious 
tax  upon  an  already  overworked  organ. 


CHAPTER  XXIV 
GOUT,  OBESITY,  EMACIATION 

Gout  is  a  constitutional  disease  characterized  by  an  inflamma- 
tory condition  of  the  joints.  It  is  caused  by  or  associated  with  a 
retention  of  uric  acid  in  the  blood.  Gout  is  also  characterized  by 
the  deposit  of  uric  acid  or  sodium  salts  which  occurs  in  different 
parts  of  the  body,  the  joints,  the  lobe  of  the  ear,  the  knee  and  the 
elbow  being  common  points  where  the  deposit  of  these  salts  ordi- 
narily occurs.  The  amount  of  uric  acid  is  lessened  in  the  urine 
in  cases  of  true  gout,  except  in  acute  attacks,  and  in  this  way  it  is 
distinguished  from  the  so-called  goutiness  in  which  a  urinalysis 
shoTvs  an  excess  of  uric  acid.  According  to  Strouse,  this  excess 
of  uric  acid  in  the  urine  "  means  a  physical-chemical  change  in 
the  urine  and  is  quite  different  from  the  small  amount  usually 
excreted."  ^ 

Source  of  Uric  Acid.  —  In  man  the  uric  acid  which  is  eliminated 
in  the  urine  is  derived  from  two  sources.  It  may  be  taken  with 
the  body  as  purins  in  food,  in  which  case  it  is  spoken  of  as  being 
an  "  exogenous  "  product,  or  it  may  be  formed  in  the  body  from 
the  breaking  down  of  the  nucleoproteins  (the  highly  nucleated 
cells  of  the  glandular  organs  particularly).  When  the  uric  acid 
is  formed  in  this  manner  as  the  result  of  the  metabolism  of  the 
body  tissues,  it  is  known  as  "  endogenous."  In  the  normal  body 
approximately  one-half  of  the  uric  acid  formed  is  oxidized,  while 
the  remaining  half  is  eliminated  from  the  body  by  way  of  the  urine. 

Elimination  of  Uric  Acid.  —  In  gout  such  is  not  the  case,  the  body 
loses  to  a  certain  extent  the  ability  to  eliminate  the  uric  acid, 
hence  it  is  retained  within  the  body,  causing  an  excess  in  the  blood 
stream,  and  it  is  this  excess  uric  acid  in  the  blood  which  causes  the 

1  "Food  for  the  Sick,"  p.  97,  by  Strouse  and  Perry. 
391 


392  DIETETICS  FOR  NURSES 

acute  attacks  and  general  pain  and  discomfort  which  inevitably 
occur  in  chronic  gout. 

Purin-bearing  Foods  as  Sources  of  Uric  Acid.  —  Formerly  no 
difference  was  made  in  food ;  all  were  supposed  to  cause  uric  acid 
formation,  but  with  the  exhaustive  investigation  of  food  materials 
this  sweeping  condemnation  has  been  to  a  great  extent  removed 
or  narrowed  down  to  a  few  foods,  those  rich  in  purins  being  the 
chief  offenders. 

Chief  Causes  of  Gout.  —  Without  a  doubt,  overeating,  over- 
indulgence in  alcoholic  stimulation,  lack  of  exercise,  etc.,  are 
chiefly  to  blame  for  the  large  percentage  of  the  cases,  but  upon 
investigation  it  will  be  seen  that  those  individuals  are  as  a  rule 
large  protein  eaters  and  that  their  mode  of  living  is  not  such  as  to 
assist  the  body  in  throwing  off  the  poisons  which  form  as  the  result 
of  their  self-indulgence. 

Rules  to  Combat  Gout.  —  To  successfully  combat  the  retention 
of  a  large  percentage  of  uric  acid  in  the  blood  there  are  certain 
definite  rules  to  be  observed  :  (1)  The  general  diet  must  be  reduced 
not  only  in  amount  but  also  in  purin-bearing  foods ;  (2)  All  foods 
which  are  liable  to  cause  digestional  disturbances,  with  the  attending 
evils  of  intestinal  putrefaction  and  constipation,  must  be  avoided. 

Alcohol  in  Gout.  —  If  the  patient  is  accustomed  to  alcoholic 
stimulants  and  has  been  in  the  habit  of  taking  them  constantly 
for  years,  the  amount  of  alcohol  consumed  daily  must  be  radically 
reduced  and  only  the  amount  prescribed  by  the  physician  taken. 
Alcohol  without  a  doubt  assists  in  the  retention  and  increases  the 
diflficulty  of  uric  acid  elimination  by  the  body.  In  view  of  the 
present  knowledge  of  the  cause  and  effect  of  uric  acid  in  the  body, 
the  treatment  of  gout  is  directed  with  the  object  of  relieving  the 
condition  (1)  by  facilitating  the  elimination  of  uric  acid  from  the 
body,  and  (2)  by  so  regulating  the  diet  as  to  exclude  as  far  as 
possible  those  purin-bearing  foods  which,  by  reason  of  their 
chemical  composition,  augment  the  general  amount  of  uric  acid 
formed  within  the  organism. 

In  gout,  as  in  other  abnormal  conditions,  no  set  rule  can  be 
laid  down  to  cover  the  treatment  of  every  case.     The  individual 


GOUT,   OBESITY,   EMACIATION  393 

must  be  taken  into  consideration,  his  daily  habits  studied  and  the 
extent  and  character  of  the  disease  known  before  it  is  possible  to 
prescribe  a  treatment  or  formulate  a  diet  which  would  adequately 
meet  his  needs  under  the  existing  conditions. 

Obesity  and  Glycosuria.  —  Gouty  individuals  often  become 
obese  and  show  evidences  of  glycosuria.  Consequently  it  is  im- 
portant to  regulate  the  carbohydrates  as  well  as  the  purin-bearing 
foods  in  the  diet.  Only  the  simplest  foods  are  permissible.  In 
acute  attacks  it  has  been  found  that  milk  and  alcohol  cause  less 
disturbance  than  meat  and  alcohol.  While  the  acute  symptoms 
exist  all  meat  should  be  avoided  and  the  daily  allowance  of  alcohol 
cut  down.  Tea  and  coffee  both  contain  pur  ins  and  should  be 
avoided  while  the  acute  stage  of  the  disease  continues.  Cereal 
coffee,  hot  water,  tea  or  hot  milk  or  buttermilk  may  be  sub- 
stituted. 

Purin-free  Diet.  —  A  purin-free  diet  is  advisable  during  the 
acute  attack.    The  following  is  a  sample  menu  of  such  a  diet : 

Breakfast  —  Banana,  apple,  grapefruit,  orange  or  peach, 
etc. 

Cereals :  farina,  hominy,  or  cream  of  wheat 
with  cream  and  sugar 

1  egg,  soft  cooked 

Buttered  toast 

Cereal  coffee  with  sugar  and  cream  or  hot- 
water  tea  (milk  and  hot  water)  with  cream 
and  sugar 

Lunch  or  Dinner — Poached  egg  on  toast,  1  large  baked  potato 
with  butter,  1  mold  of  fruit  jelly  with 
cream' 

Supper  —  Rice  and  butter,  bread  or  toast  with  hot  milk. 
Apple  sauce  with  cream. 

Pttrin  Pbb  Cent 

Cocoa  contains 1 .00  per  pint 

Tea  "       1.20  per  pint 

Coffee        "       ..'...     1.70  per  pint 


394  DIETETICS  FOR  NURSES 

Purins  are  soluble  in  water,  hence  those  foods  that  are  boiled 
contain  less  than  those  prepared  by  other  methods  of  cookery. 

Foods  More  or  Less  Condemned.  —  Salt  has  a  tendency  to 
bring  about  a  deposit  of  sodium  urates  in  the  body,  and  for  this 
reason  should  be  sparingly  used  in  the  preparation  of  the 
diet.  Alkaline  waters  are  inclined  to  produce  a  like  result, 
consequently  should  be  avoided  by  the  gouty  individual.  Con- 
diments and  spices  are  conducive  to  constipation,  a  condition 
to  be  avoided  if  possible  under  the  circumstances.  Certain 
physicians  prohibit  the  use  of  oranges  in  the  diet  of  gout, 
while  others  do  not.  Strawberries  are  likewise  condemned  and 
should  be  eliminated  from  the  diet  for  both  chronic  and  acute  gout. 

Diet  in  Chronic  Gout.  —  In  chronic  gout  it  is  necessary  to 
maintain  the  general  health  of  the  patient  by  a  well-balanced  diet. 
This  is  not  difficult  even  if  the  dietary  is  so  regulated  as  to  be 
well  within  the  limits  of  his  energy  requirements.  It  is  necessary 
to  limit  the  purin-bearing  foods.  Meats  are  used  sparingly  and 
these  should  be  boiled  rather  than  roasted  or  broiled.  Eggs  and 
cheese  and  milk  should  be  substituted  for  at  least  part  of  the 
regular  allowance  of  meat. 

Exercise  and  Massage.  —  The  patient  should  be  recommended 
to  take  a  certain  amount  of  mild  exercise  in  the  open  air  or  massage 
if  he  is  accustomed  to  living  an  indoor  life  or  is  confined  to  office 
work.  He  must  be  warned  against  over-indulgences  of  all  kinds, 
especially  of  overeating  and  drinking.  A  glass  or  two  of  hot 
water  before  breakfast  is  recommended. 

Treatment  of  Obesity.  —  The  treatment  of  obesity  when  occur- 
ring in  gouty  patients  is  much  like  that  used  in  other  conditions. 
Ebstein  regards  obesity  under  such  circumstances  as  an  unfavor- 
able symptom.  He  advises  a  reduction  in  the  carbohydrates  to 
the  smallest  possible  amount  and  allows  meat  and  fats  in  the  diet. 

Allowable  Foods.  —  The  following  foods  are  practically  purin- 
free  and  may  be  used  in  the  diet  for  gout :  ^  Milk,  cheese,  butter, 
eggs,  nuts,  gelatine,  fruits,  sugar,  breads  made  with  white  flour, 

'  The  amount  of  food  must  be  limited,  since  overeating  will  precipitate  an  acute 
attack.  It  is  best  to  limit  the  amount  to  about  a  maintenance  allowance  or  a 
little  more,  temporarily. 


GOUT,   OBESITY,   EMACIATION  395 

cereals,  cream  of  wheat,  farina,  rice,  hominy,  tapioca,  cornstarch, 
potatoes  and  other  root  vegetables,  green  vegetables,  except 
asparagus,  spinach,  and  all  fats. 

Avoidable  Foods.  —  The  following  foods  are  rich  in  purins  and 
should  be  avoided  in  the  diet  for  gout :  Sweetbreads,  liver, 
kidneys,  beef,  mutton,  veal,  pork,  turkey,  chicken,  goose,  rabbit, 
duck  and  other  game,  fish,  with  the  exception  of  cod,  sardines,  and 
anchovies,  tea,  coffee,  and  cocoa. 

The  following  list  shows  the  purin  content  of  some  of  the  above- 
mentioned  foods.  The  purins  are  computed  by  Hall  as  follows : 
1  kilogram  contains, 

Gbams  Purin 
Milk 
Butter 
Eggs 
Cheese 
Farina 
Rice 
Hominy 

Potato 0.02 

Asparagus       ......     0.21 

Lentils 0.38 

Halibut 1.00 

Cod 05 

Salmon 1.00 

Mutton 0.96 

Beef 1.10-2.00 

Veal 1.10 

Ham 1.10 

Pork 1.20 


Grams  Purin 

Flour 

Bread 

Cauliflower 

Eggplant 

Cabbage 

Lettuce 

Sugar 

Peas      .     .     . 

.     .    0.39 

Oatmeal     .     . 

.     .    0.53 

Beans    .     .     . 

.     .    0.63 

Chicken     .     . 

.     .     1.20 

Sherry 

Claret 

Whisky 

Brandy 

Beer      .     .     . 

.     .    0.12 

Porter   .     .     . 

.     .    0.14 

Ale    ...     . 

.     .    0.14 

Chocolate  .     . 

.     .    0.70  per  pint 

To  keep  the  body  in  good  condition  and  to  help  rid   it   of 
accumulated  poisons,  the  following  diet  lists  are  recommended : 
Daily  Dietaries : 

7  A.M.  — Hot  water,  8  oz. 

8  A.M. 

Breakfast — -Stewed  prunes,  wheatena  and  cream 
2  eggs 

2  slices  of  buttered  toast 

1  cup  of  milk  flavored  with  cocoa  or  coffee  or  1  cup 
of  cereal  coffee  with  cream 


396  DIETETICS  FOR  NURSES 

Dinner  —  Cream  of  pea  soup 

Boiled  codfish  with  cream  sauce 
Mashed  potatoes 
Cauliflower 
Rice  pudding 

Supper  —  Cream  toast 

Baked  potatoes 
Egg  nest 
Apple  sauce 

Hot  milk  flavored  with  coffee,  cocoa,  or  1  cup  of 
cereal  coffee 

7  A.M.  — Hot  water,  8  oz. 

8  A.M. 

Breakfast  —  Grapefruit 

Cereal  and  cream 

Soft  scrambled  eggs 

Cereal  coffee,  or  milk  and  coffee 

Buttered  toast 

12:30 

Lunch  —  Cream  of  tomato  soup 

Cottage  cheese  and  cream 

Baked  potato 

Baked  apple 

Bread  and  butter 

6  P.M. 
Dinner  —  Chicken,  small  piece,  no  gravy  or  rich  dressing 
Candied  sweet  potatoes 
Baked  eggplant 

Lettuce  salad  (lemon  juice  instead  of  vinegar) 
Bread  and  butter 
Orange  or  wine  jelly 
Milk 


GOUT,   OBESITY,   EMACIATION  397 

Breakfast — Cereal  and  cream 

Baked  apple  with  cream 

1  slice  of  bacon 

1  soft-cooked  egg 

Toast  —  butter 

Cereal  coffee,  or  milk  flavored  with  coffee 

Lunch  —  Vegetable  soup 

Scalloped  potatoes 
Cream  cheese 
Bread,  butter 
Stewed  pears 

Dinner  —  Halibut  steak 

Creamed  potatoes 

String  beans 

Fruit  salad 

Sponge  cake,  orange  sauce 

Small  coffee 

OBESITY 

Probably  no  one  problem  affecting  the  human  family  is  more 
widely  discussed  than  that  of  obesity.  There  are  numberless 
"  cures  "  suggested,  most  of  which  contain  some  good,  but  they 
are  as  a  rule  more  strenuous  than  the  average  fat  person  cares  to 
attempt,  or,  if  attempted,  persist  in. 

Causes  of  Obesity.  —  It  is  stated  that  at  least  fifty  per  cent 
of  the  obesity  is  of  hereditary  origin,  while  the  rest  may  be  due 
to  overeating  and  drinking,  unbalanced  diets,  metabolic  changes 
due  to  the  approach  of  menopause  in  women,  and  diseases  such 
as  gout  in  which  there  is  a  certain  amount  of  disturbance  in  the 
blood  and  excretory  organs  and  in  which  the  diet  or  the  disease 
may  be  accountable  for  the  gain  of  surplus  adipose  tissue.  Women 
approaching  menopause  may  not  change  their  diet  in  the  least 
and  there  may  still  be  the  noticeable  increase  of  fat. 

Obesity  Cures.  —  A  great  number  of  the  "  cures  "  are  under- 
taken not  from  a  health  standpoint  but  from  the  esthetic  point 


398  DIETETICS  FOR  NURSES 

entirely.  It  makes  no  difference  what  reason  is  brought  forward 
for  instituting  the  treatment,  it  is  the  results  which  count.  Of  the 
cures  undertaken  which  are  in  themselves  good,  but  which  are 
too  strenuous  for  the  average  "  fat  person  ^'  to  stick  to  may  be 
mentioned  some  of  the  early  cures  instituted  and  recommended  by 
Banting,  Oertel,  and  Ebstein.  Obesity,  then,  may  be  said  to  be 
due  to  (1)  heredity,  (2)  overeating  and  drinking,  (3)  lack  of  exercise 
(sedentary  life),  (4)  a  combination  of  the  above  causes.  WTiether 
the  obesity  is  due  to  the  lack  of  exercise  or  the  lack  of  exercise  is 
due  to  the  accumulation  of  fat  which  causes  a  disinclination  to 
move  on  the  part  of  the  individual,  can  only  be  judged  when  a 
thorough  examination  into  the  life  and  habits  of  the  patient  is  made. 

Comparison  of  Food  Intake  and  Energy  Output.  —  Many  fat 
people  who  claim  to  be  small  eaters  in  reality  constantly  consume 
more  food  than  their  age,  weight,  or  mode  of  living  would  necessi- 
tate. If  such  patients  could  be  prevailed  upon  to  keep  a  correct 
chart  of  their  daily  intake  of  food  and  the  amount  of  exercise 
taken,  they  would  be  astounded  to  find  how  much  greater  was 
the  intake  in  comparison  to  the  output  of  energy,  in  other  words, 
how  much  more  food  they  ate  than  they  required  to  keep  them  in 
health.  A  glance  at  the  first  tables  in  this  text  will  show  which 
foods  are  utilized  by  the  body  chiefly  as  a  source  of  energy. 

Uses  of  Food  in  Body.  —  Physiological  chemistry  proves  that 
when  more  food  is  taken  than  is  needed  for  the  internal  and  external 
work  of  the  body,  the  surplus  is  stored  for  future  use,  first,  in  the 
liver  and  muscles  as  glycogen  for  the  general  expenditures,  and, 
second,  as  adipose  tissue  for  future  use.  Thus  it  is  seen  that  when 
the  intake  is  constantly  greater  than  the  energy  expenditure  there 
must  necessarily  be  some  way  in  which  the  body  can  store  up  her 
surplus  fuel,  and  so  long  as  the  digestion  remains  good  and  the 
amount  of  exercise  limited  there  is  no  reason  why  there  should 
not  be  a  constant  and  steady  accumulation  of  surplus  fat  which 
inevitably  terminates  in  obesity. 

Water  as  a  Fat  Maker.  —  That  water  is  in  itself  fattening  is  of 
course  untrue.  A  chemical  analysis  of  this  fluid  shows  that  it 
is  inorganic  in  character  and  cannot  alone  either  produce  energy 


GOUT,  OBESITY,  EMACIATION  399 

or  build  tissue.  However,  this  food  constituent  plays  a  most 
important  part  in  all  the  functions  of  the  body.  In  the  first  place 
the  body  cannot  utilize  food  unless  it  is  in  solution ;  water  is  also 
one  of  the  best  known  stimuli  to  the  flow  of  gastric  juice,  and  for 
this  reason  is  an  important  factor  in  the  preparation  of  the  food 
for  its  absorption  and  utilization ;  since  water  forms  the  bulk  of 
the  blood,  it  acts  as  a  distributer  or  carrier  of  food  to  the  different 
parts  of  the  body. 

Limiting  the  Fluids  in  Obesity.  —  Thus  it  is  seen  that  when 
the  intake  of  fluids  is  limited,  the  body  will  call  upon  that  surplus 
which  is  stored  in  every  nerve,  tissue,  and  fluid  throughout  the  entire 
organism  to  assist  in  the  necessary  work  of  the  organs,  thus  reducing 
the  body  weight  just  that  much. 

Exercise.  —  The  athlete  who  is  overweight,  due  to  adipose 
tissue,  increases  his  exercise  at  times,  even  adding  to  the  weight 
of  his  clothing,  causing  an  increased  energy  output,  profuse 
perspiration,  etc.,  all  of  which  causes  the  body  to  use  her  surplus 
fuel  in  the  form  of  the  stored  fat.  Exercise  does  not  break  down 
a  muscle,  it  builds  it  up.  Thus  many  individuals  who  increase 
the  strenupusness  of  their  exercise  complain  that  their  weight  is 
increased  even  when  they  observe  a  noticeable  improvement  in 
their  general  feelings  and  appearance. 

The  Appetite.  —  The  great  trouble  with  most  women  who  under- 
take an  obesity  cure  which  calls  for  an  increased  amount  of  energy 
is  that  they  will  develop  an  increased  appetite  thereby  which  they 
appease  with  food  instead  of  forcing  the  body  to  use  the  store 
in  hand,  thus  entirely  doing  away  with  any  good  the  treatment 
might  have  accomplished.  No  amount  of  exercise  without  a 
proper  regulation  of  the  diet  will  prove  satisfactory  as  far  as  the 
reduction  of  fat  is  concerned.  The  following  methods  recom- 
mended by  Banting,  Oertel,  and  Ebstein  are  included  here. 

OBESITY  DIETS   AND   CURES 

Banting  Method.  —  This  method  is  said  to  be  unsuited  to  those 
with  weak  digestions.  Following  its  use  such  individuals  have 
been  known  to  develop  renal  colic  or  gallstones;    constipation 


400  DIETETICS  FOR  NURSES 

may  be  present  and  the  entire  system  may  become  so  deranged 
as  to  render  the  patient  Hable  to  disease.^ 

Banting  Diet  for  Obesity.  —  Breakfast  at  9  a.m.,  consisting  of 
5-6  ounces  of  animal  food,  meat  or  boiled  fish  (except  pork  or 
veal) ,  1  small  biscuit  or  1  ounce  dry  toast.  Total  solids,  5-6  ounces. 
Coffee  or  tea  (without  milk  or  sugar),  9  ounces. 

2  P.M.  —  Dinner :  Fish  or  meat  (salmon,  eels,  herring,  pork, 
and  veal  excepted),  poultry  or  game;  any  vegetable  except  pota- 
toes, parsnips,  carrots,  turnips,  or  beet  roots ;  dry  toast,  1  ounce ; 
fruit  cooked  and  unsweetened ;  good  claret,  sherry,  or  Madeira, 
10  ounces.     Total  solids,  10-12  ounces. 

6  P.M.  —  Tea :  2-3  ounces  cooked  fruit ;  1-2  ounces  rusks ;  24r- 
ounces  solids ;   9  ounces  tea^  without  milk  or  sugar. 

7  P.M.  —  Supper :  Meat  or  fish  as  at  dinner ;  claret  or  sherry 
and  water,  7  ounces. 

Total  daily  solids,  21-27  ounces. 

Total  fluids,  35  ounces. 

Oertel  pointed  out  the  great  benefits  which  might  be  derived  by 
those  individuals  suffering  from  certain  types  of  heart  disease 
which  are  accompanied  by  obesity.  He  made  it  distinctly  under- 
stood that  while  the  treatment  in  no  way  affected  the  heart  lesion, 
—  that  is,  in  so  far  as  altering  the  character  of  the  disease,  —  it 
greatly  reduced  the  work  imposed  upon  the  circulatory  organ  and 
permitted  a  more  complete  oxidation  of  the  blood. "* 

Oerters  Method.  —  Oertel  bases  his  dietetic  treatment  of 
obesity  upon  the  heart  changes  and  those  which  naturally  follow 
in  the  circulation.  He  makes  the  following  suggestions,  taking 
always  into  consideration  the  condition  of  the  patient,  whether 
he  is  anemic  or  plethoric. 

"  (a)  Where  there  is  an  abnormally  increased  amount  of  fat 
in  plethoric  patients  with  unimpaired  or  only  beginning  changes 
in  the  heart  action,  the  diet  should  aim  at : 

(1)  An  increased  supply  of  protein. 

(2)  A  decrease  in  the  fat-forming  substances. 

•  "Diet  in  Health  and  Disease,"  by  Freidenwald  and  Ruhrah. 

*  Ibid.,  p.  544,  by  Freidenwald  and  Ruhrah. 


GOUT,   OBESITY,   EMACIATION 


401 


(3)  Little  or  no  diminution  in  the  supply  of  liquids  below  the 
physiologic  amount  (1500  c.c.-3  pt.) 

(6)  Where  there  is  obesity  in  anemic  patients,  viz.  serious 
plethora,  the  diet  should  aim  at : 

(1)  An  increase  in  the  quantity  of  proteins. 

(2)  A  diminution  in  amount  of  fat-forming  substances  and 
eventually 

(3)  A  decrease  in  the  amount  of  fluid. 

(c)  Where  there  is  obesity  in  adults  with  anemic  symptoms 
in  whom  not  only  the  amount  of  protein  but  also  the  abnormally 
increased  amount  of  fat  is  slowly  wasting  away,  they  require : 

(1)  An  increase  in  the  amount  of  protein  taken. 

(2)  A  sufficient  amount  of  fat  and  carbohydrates  or  even  an 
increase  of  same  to  prevent  the  falling  off  of  fat. 

(3)  A  diminution  in  the  amount  of  fluid  taken.'* 

Oertel  claims  that  the  simplest  method  of  reducing  the  fat- 
forming  elements  in  a  diet  is  to  decrease  the  amount  of  fat  and 
allow  a  certain  amount  of  carbohydrates,  regulating  the  diet 
according  to  the  individual.  The  following  table  is  given  by  him 
as  showing  the  minimum  and  maximum  amount  of  the  different 
food  constituents  constituting  the  obesity  diet : 


Protein 
Gm. 

Fat 
Gm. 

Carbo- 
hydrate 
Gm. 

Calories 

Minimum      .... 
Maximum 

156 
170 

25 
45 

75 
120 

1180 
1608 

In  instituting  a  treatment  for  obesity  Oertel  insists  upon  a 
certain  amount  of  exercise  daily  in  the  open  air,  the  amount  to 
be  regulated  by  the  physician  according  to  the  individual  case. 
He  suggests  that  five  or  six  small  meals  a  day  be  given  rather 
than  a  few  large  meals.  He  eliminates  soups,  tea,  and  coffee  while 
the  cure  is  being  given. 

Ebstein  suggests  a  diet  in  which  the  carbohydrates  and  fluids 
are  reduced  but  in  which  the  fats  are  allowed  to  a  considerable 
2d 


402  DIETETICS  FOR  NURSES 

extent.    The  diet  consists  of  meat,  eggs,  fish,  vegetables  (green) 
and  fruits.     The  following  menu  demonstrates  his  dietary  regime : 

Breakfast :  Large  cup  of  tea  (no  milk  or  sugar) ;  2  oz.  bread 
with  plenty  of  butter. 

Dinner :  Soup  4^  to  5^  oz. ;  meat  with  fat  sauce ;  green 
vegetables ;   fresh  fruit ;   2-3  glasses  light  wine. 

Afternoon :  Tea  as  at  breakfast. 

Supper:  Tea,  1  egg,  fat  roast  meat  or  ham,  smoked  fish; 
about  1  oz.  bread  with  plenty  of  butter ;  a  little  cheese  and  fresh 
fruit ;   potatoes,  sweets  and  sugars  forbidden. 

Dietetic  Treatment.  —  The  following  menus  are  suggested  by 
the  author :  The  carbohydrates  and  fats  are  restricted  and  the 
fluids  reduced  to  a  minimum.  The  meals  as  far  as  possible  are 
kept  "  dry " ;  soups,  milk,  cocoa  are  avoided ;  water  is  not 
permitted  at  meals;  alcoholic  beverages,  white  bread,  butter, 
potatoes,  sugar,  candy,  pastry,  cakes,  puddings,  gravies,  sauces, 
bread  dressings,  griddle  cakes,  sirups,  molasses,  honey,  ice  cream, 
cereals,  pork  of  all  sorts,  ham,  bacon,  pork  chops,  etc.,  olive  oil, 
spaghetti,  macaroni,  and  noodles  are  prohibited. 

Allowable  Foods.  —  The  following  foods  are  allowed :  Black 
coffee  or  tea,  small  cup  twice  daily  without  milk,  cream,  or  sugar  — 
saccharine  may  be  used  to  sweeten  if  desired ;  fresh  or  stewed  fruit 
with  the  exception  of  bananas,  raisins,  and  dates,  served  without 
sugar ;  all  green  vegetables  cooked  or  served  without  butter  or  fat 
of  any  description ;  salads,  except  potato  or  banana,  served  with  a 
special  dressing  (no  oil  or  sugar)  ;  water  ices ;  watermelon  and  other 
melons  served  without  sugar ;  1  egg  a  day ;  gluten  toast,  no  butter ; 
brown  bread  or  muffins  made  with  gluten  flour  and  prepared  bran. 

The  following  menus  may  be  used  as  guides  in  the  treatment 
of  obesity : 
Breakfast  —  1  sliced  orange  (no  sugar) 

1  small  cup  coffee  or  tea  without  cream,  milk,  or 

sugar  (sweeten  with  saccharine  if  desired) 
1  poached  egg  on 

1  slice  of  gluten  toast  (no  butter) 

Lunch  —  Cottage  cheese  and  lettuce  salad  with  special  dressing 

2  broiled  lamb  chops 


GOUT,   OBESITY,   EMACIATION  403 

^  1   slice  gluten  bread;    3  ounces   (1  serving)  apple 
sauce  (sweetened  if  necessary  with  saccharine) 
Dinner  —  Roast  beef 

Spinach  or  greens  (cooked  without  fat  meat) 
Green  peas 

Tomato  and  lettuce  salad  with  special  dressing 
Orange  or  wine  jelly  (sweetened  with  saccharine) 
1  slice  of  gluten  bread  or  toast 
7  A.M.  or  1  hour  before  breakfast  —  1  cup  of  water  containing 
juice  of  i  lemon. 
Breakfast  — i  grapefruit  without  sugar 

1  small  cup  black  coffee  or  tea 
Beefsteak  broiled  and  served  without  butter  (lean) 
1  slice  of  gluten  toast 
Lunch  —  Tuna  fish  salad  (no  olive  oil  in  dressing) 

1  bran  muffin  or  1  slice  (1  oz.)  gluten  toast 
1  baked  apple  (without  cream  or  sugar) 
Dinner  —  Roast  or  boiled  chicken  (no  gravy  or  bread  dressing) 
Green    vegetables    (peas,    string    beans,    cabbage,^ 

turnips,  artichokes  (without  butter)). 
Fruit  salad  (special  dressing). 
Lemon  ice. 
Amount  of  Food.  —  The  amount  of  food  is  limited  to  a  certain 
extent.     Green  vegetables  may  be  eaten  in  abundance,  but  the 
protein  foods  such  as  meat,  fish  and  eggs  must  be  limited.^     The 
bread  (even  gluten  and  bran  breads)  must  be  limited  to  1-2 
slices  at  each  meal.     All  meals  are  eaten  without  fluids  except 
breakfast,  when  one  small  cup  of  coffee  or  tea  without  milk, 
cream,  or  sugar  is  allowed.     If  fruit  juice  is  to  be  served  instead 
of  fruit,  it  must  be  prepared  with  little  if  any  water  and  no  sugar. 
The  juice  may  be  poured  over  cracked  ice,  if  desired. 

The  following  reducing  diet  is  suggested  by  Dr.  Rose  for  the 
use  of  over-fat  women : 

B  Boiled  vegetable  dinners  must  be  prepared  without  fat  meat  and  potatoes. 

*  Scientific  investigation  has  proved  that  both  carbohydrates  and  fats  may  be 
formed  in  the  body  from  protein.  Hence  any  excess  above  that  required  to  keep 
the  body  in  nitrogen  equilibrium  is  utilized  by  the  organism  for  fuel  or  stored  as  fat. 


404 


DIETETICS  FOR  NURSES 


REDUCING   DIET   FOR  OBESE   WOMEN ' 

Fuel  value  1052  calories  —  ordinary  requirements  2200  calories 


Breakfast 

Apple 

Egg 

Toast 

Coffee  7 

Skim  milk      .... 

10 :  30  A.M. 
Bouillon     .     .     .     .     . 
Water  cracker     .     .     . 

Luncheon 

Lean  cold  roast  beef     . 
Rye  bread      .... 
Lettuce    and    cottage 
cheese  salad : 

Lettuce  .     .     .    ". 
Cheese    .... 

4 :  30  P.M. 

Tea  with  lemon  »     .     . 
Water  cracker     .     .     . 

Dinner 
Boiled  cod  with  lemon 
Boiled  potato      .     .     . 
Cauliflower  (plain)  .     . 

Butter 

Watercress  and  egg  salad 

Watercress      .     .     . 

Egg 

French  dressing .     .     . 

Orange       

Black  coffee  .     .'     .     . 

10 :  30  P.M. 

Hot  skim  milk    .     .     . 
Total  calories       .     . 


Measure 


1  medium 

1  ^^g 
1  slice 
1  cup 
1^  tbs. 


h  cup 
1  cracker 


Medium  serving 
2  thin  sUces 


Ad  libitum 


2|  tbs. 


1  cup 
1  cracker 


Large  serving 
I  medium 
Large  serving 
1  tsp.  (scant") 

Ad  libitum 
1  egg 
I  tbs. 
h  large 
Demi-tasse 


cup 


Weight 
Oz. 

Protein 
Calories 

4.9 
2.4 
0.5 

2 
27 

7 

1.0 

3 

4:0 

0.1 

10 
1 

3.5 
0.7 

97 

7 

40 

0.1 

1 

8.2 
1.8 
3.0 
0.1 

209 
6 
6 

27 

4.7 

3 

4.3 

16 

Total 
Calories 


65 
75 
50 

10 


12 
10 


150 
50 


85 


10 


225 
50 
25 
30 


110 
50 

45 


1052 


^  "  Feeding  the  Family,"  p.  84,  by  Mary  Swartz  Rose. 
8  Saccharine  may  be  used  to  sweeten. 


GOUT,   OBESITY,   EMACIATION 


405 


AUTHOR'S  REDUCING  DIET 

Approximate  fuel  value  965.5 


Material 

Amount 

Protein 
Gm. 

Carbohy- 
drate 
Gm. 

Fat 
Gm. 

Calories 

Breakfast 

Orange      .... 

1  medium 

1.5 

17.4 

0.3 

78.3 

Poached  egg .     .     . 

1  egg 

5.3 

4.6 

62.6 

on 

Toast  (gluten)   .     . 

1    slice    (1 

oz.) 

8.4 

8.5 

0.3 

70.3 

Coffee  (black)    .     . 

1  cup 

211.2 

Luncheon 

Lettuce    and    cot- 

tage cheese  salad  : 

/ 

Lettuce .     .     . 

Ad  libitum 

Cheese  .     .     . 

2  tbs. 

5.9 

1.2 

0.2 

30.2 

Dressing     .     . 

1  tbs. 

1.5 

3.4 

36.6 

Lamb  chop   .     .     . 

1  chop 

9.2 

12.7 

151.3 

Gluten     bread     or 

toast 

1  slice 

8.9 

8.5 

0.3 

70.3 

Apple  sauce  .     .     . 

1     serving 
about   i 

cup 

0.6 

22.5 

.7 

97.5 

385.9 

Dinner 

Roast  beef    .     .     . 

2          thin 
slices   (2 

oz.) 

11.4 

4.8 

88.8 

Spinach    .... 

h  cup 

2.3 

3.6 

0.3 

26.3 

Green  peas    .     .     . 

\  cup 

4.8 

11.1 

0.2 

65.4 

Lettuce     .... 

Ad  libitum 

Tomato    .... 

1  medium 

0.4 

3.1 

0.2 

15.8 

Dressing  .... 

1  tbs. 

1.5 

3.4 

36.6 

Orange  jelly : 

Orange  juice  .     . 

h    cup    (8 

tbs.) 

14.2 

56.8 

Lemon  juice  .     . 

1  tbs. 

Gelatine     .     .     . 

1  tsp. 

2.1 

8.4 

Water   .... 

1  tbs. 

Saccharine 

1       tablet 
or  less 

Bread,  gluten    .     . 

1  slice 

8.4 
72.2 

8.5 
98.6 

0.3 
31.7 

70.3 

Total  grams      .     .     . 

368.4 

Total  calories   .     .     . 

965.5 

406 


DIETETICS   FOR   NURSES 


AUTHOR'S  REDUCING  BIET  —  Continued 
Approximate  fuel  value  930.5 


Material 

Amount 

Protein 
Gm. 

Carbohy- 
drate 
Gm. 

Fat 
Gm. 

Calories 

Breakfast 

Fruit 

1  orange 

0.85 

12.05 

0.15 

53.0 

Gluten  toast      .     . 

2  slices 

17.8 

17.0 

0.6 

140.0 

Egg     (poached    or 

soft  cooked)   .     . 

1  egg 

5.3 

4.6 

60.0 

Coffee 

1  cup 

253.0 

Luncheon 

Oyster  cocktail .     . 

6  oysters 

3.5 

4.20 

0.68 

37.0 

Cold  roast  beef  .     . 

1    slice    (1 

oz.) 

5.7 

2.4 

44.0 

Coleslaw:      .     .     . 

|cup 

Cabbage    .     .     . 

1  cup 

0.002 

0.001 

0.034 

4.5 

Dressing    .     .     . 

1  tbs. 

1.5 

3.4 

36.0 

Gluten  toast      .     . 

2  shces 

17.8 

17.0 

0.6 

140.0 

261.5 

Dinner 

Chicken     (without 

3   oz.    one 

stuffing)     .     .     . 

serving 

18.2 

2.1 

92.0 

Broiled  mushrooms 

6   medium 

size 

1.5 

3.0 

0.18 

19.0 

String  beans      .     . 

3   oz.    one 

serving 

1.95 

6.29 

2.29 

34.4 

Pineapple  salad : 

Lettuce      .     .     . 

Ad  hbitum 

Pineapple  .     .     . 

1  slice 

4.0 

31.0 

0.6 

129.5 

Dressing    .     .     . 

1  tbs. 

1.5 

2.4 

37.0 

Apple  float 

1  apple      .     .     . 

1  apple 

0.6 

22.2 

0.77 

98.1 

^  egg  white    .     . 

^  egg  white 

1.5 

0.02 

6.0 

Saccharine  to 

sweeten 

416.0 

Total  calories 

930.5 

Rules  and  Regulations.  —  The  following  directions  and  menus 
are  given  to  be  used  when  a  reduction  in  weight  is  necessary. 
Care  must  be  taken  not  to  allow  large  amounts  of  even  the  non- 
fat-forming foods  in  the  dietary,  since  under  certain  conditions 
the  body  will  manufacture  adipose  tissue  of  any  surplus  organic 


GOUT,   OBESITY,   EMACIATION  407 

material  ingested.  Breakfast  must  be  limited  as  demonstrated 
in  the  tabulated  diet  sheet. 

Keeping  the  Weight  Down.  —  After  the  individual  has  been 
reduced  to  approximately  the  desired  weight  the  diet  may  be  made 
a  trifle  more  liberal,  keeping  in  mind,  however,  that  moderation 
is  the  keynote  in  the  obesity  regime  and  will  have  to  be  practiced 
to  a  certain  extent  always.  It  is  wise  to  continue  the  dry  meals 
and  to  limit  the  amount  of  butter,  cream,  and  other  "  fatty  foods," 
to  a  certain  extent.  Pork,  with  the  exception  of  crisp  bacon  sev- 
eral times  a  week  at  breakfast,  had  best  be  avoided,  and  alcoholic 
beverages  should  be  omitted  entirely  except  when  prescribed  by 
the  physician.  The  outdoor  exercise  should  be  continued  and 
only  the  amount  of  sleep  requisite  to  health  indulged  in.  If  the 
individual  will  faithfully  carry  out  these  directions,  there  is  no 
reason  why  the  weight  should  continue  to  be  a  burden.  It  must 
be  remembered  that  it  is  never  safe  to  diet  indiscriminately  and 
w  ithout  the  advice  of  a  physician,  since  much  harm  may  come  of 
so  doing. 

Value  of  Massage.  — Massage  is  an  advisable  accompaniment  to 
an  obesity  diet  and  will  help  to  prevent  a  sagging  of  the  tissues 
which  have  been  deprived  of  the  supporting  fat.  The  tissues  of 
the  face,  neck,  and  breast  are  especially  apt  to  wrinkle  unless 
given  the  exercise  and  stimulation  from  massage.  Cold  baths 
are  likewise  advisable,  since  they  stimulate  the  body  to  burn  up 
the  fat. 

OBESITY  MENUS 

Lunch  —  Tuna  fish  salad 
Cauliflower 
Baked  apple 

Dinner  —  Soft-shell  crabs 
Roast  lamb 
Spinach 
Tomato  jelly 
Grapefruit 


408  DIETETICS  FOR  NURSES 

Lunch  —  Corned  beef  and  cabbage 
Stewed  pears 

Dinner — Clam  cocktail 
Roast  chicken 
Asparagus 
Fruit  salad 

Lunch  —  Broiled  oysters ;  cold  lamb 
Boiled  turnips 
Water-cress  salad 

Dinner  —  Roast-beef 

Stewed  tomatoes 
String  beans 

Lettuce  and  tomato  salad 
Sliced  peaches 

Lunch  —  Broiled  calves'  liver 

Greens  (mustard,  turnip,  beet  tops,  or  dandelion) 
Orange  jelly 

Dinner  —  Crab-flake  cocktail 
Broiled  squab 
Artichokes 
Stewed  celery 
Lettuce,  Russian  dressing 

Lunch  —  Kippered  herring 

Veal  croquettes  (baked  instead  of  fried,  with  tomato 
sauce ;  this  dressing  is  made  by  adding  1  teaspoonful 
of  chili  sauce  to  the  regular  dressing  used  in  obesity 
diets) 

Asparagus 

Apple  sauce 

Dinner  —  Baked  halibut  steak,  stuffed  with  oysters 
Boiled  onions 
Boiled  carrots 
Pineapple  and  grapefruit  salad 


GOUT,  OBESITY,  EMACIATION  409 

Lunch  —  Broiled  calves'  brains 
Vegetable  salad 
Melon 

Dinner  —  Broiled  chicken 
Boiled  beets 
String  beans 

Cucumber  and  young  onion  salad 
Raspberry  ice 

Lunch  —  Stuffed  eggs 

Sliced  tongue  with  spinach  or  greens 

Carrots  or  beets 

Fruit 

Dinner  —  Roast  turkey,  cranberry  sauce 
Cauliflower 
Tomatoes  stuffed  with  celery,  green  peppers  and  onion 

dressing 
Peach  whip 

Lunch  —  Hashed  beef 
Boiled  onions 
Stewed  prunes 

Dinner  —  Oysters 

Baked  rabbit 
Eggplant  (baked) 
Spinach 
Fruit  jelly 

EMACIATION 

Emaciation  as  a  rule  is  a  symptom  of  an  abnormal  condition 
rather  than  a  disease  in  itself.  Certain  individuals  are  said  to  be 
"  constitutionally  thin  "  and  upon  investigation  it  is  often  found 
that  this  thinness  extends  back  in  many  cases  for  generations, 
many  members  of  a  family  being  thin  no  matter  what  measures 
are  taken  to  overcome  the  condition.  However,  constitutional 
emaciation  is  not  so  prevalent  as  constitutional  obesity  and,  as 


410  DIETETICS  FOR  NURSES 

has  already  been  stated,  is  more  often  a  symptom  of  some  metabolic 
disturbance  or  pathological  condition. 

Causes  of  Emaciation.  —  Errors  in  diet  —  insufficient  or  im- 
proper food — are  accountable  for  most  of  the  cases  seen  in  infants 
and  children.  Over-exercise,  that  is,  when  the  amount  of  exercise 
taken  is  not  commensurate  with  the  intake  of  food,  is  accountable 
for  other  cases.  This  type  of  emaciation  is  found  especially  in 
growing  children. 

Disease  as  a  Cause.  —  Wasting  diseases,  such  as  tuberculosis 
and  anemia,  bring  about  a  loss  of  weight,  while  in  fevers  in  general 
and  typhoid  fever  especially  not  only  the  febrile  condition  hastens 
the  metabolic  processes  but  also  the  activities  of  the  bacteria 
act  together  and  break  down  the  tissues  of  the  body,  causing  a 
falling  off  from  the  normal  body  weight.  Loss  of  sleep,  unhygienic 
or  unsanitary  surroundings,  and  capricious  appetites  probably 
cause  some  of  the  cases  of  excessive  thinness. 

Thinness  in  Children.  —  Parents  are  to  blame  for  much  of  the 
thinness  seen  in  children,  especially  the  nervous  high-strung  chil- 
dren whose  energies  outweigh  their  desire  for  food  or,  as  is  more 
often  the  case,  their  willingness  to  eat  the  proper  foods.  It  is  a 
mistaken  kindness  to  cater  to  the  whims  and  fancies  of  a  child's 
appetite,  and  much  harm  is  wrought  by  allowing  the  "  trash  " 
to  overbalance  the  necessary  building  or  repair  food  in  the  dietary. 
Not  that  sugar  is  not  necessary,  for  it  is  particularly  so  at  the  age 
when  the  metabolic  processes  are  faster  than  later  in  life,  but  it 
must  be  remembered  that  the  body  is  being  built  up  both  in  height 
and  breadth. 

The  Need  for  Building  Foods.  — The  skeleton  and  the  muscular 
tissues  cannot  be  constructed  from  sugar,  hence  the  diet  which 
consists  chiefly  of  this  food  constituent  is  unbalanced  and  will 
sooner  or  later  bring  about  disturbances  which  are  very  apt  to 
result  in  emaciation.  The  causes  of  emaciation  may  be 
summarized  as  follows : 

(1)  Those  cases  which  are  due  to  pathological  conditions  such 
as  tuberculosis,  anemia,  typhoid  fever,  etc. ; 

(2)  Those  induced  by  errors  in  diet  and  bad  habits  such  as 


GOUT,  OBESITY,  EMACIATION  411 

insufficient  or  improper  food,  loss  of  sleep,  over-exercise,  lack  of 
ventilation  in  the  sleeping  apartment,  which  destroys  the  appetite ; 

(3)  Malformation  or  deformities  of  mouth,  throat,  or  stomach 
which  make  it  impossible  for  the  individual  to  partake  of  suffi- 
cient food  to  cover  the  needs  of  the  body ; 

(4)  Heredity  ("constitutional  thinness")- 

Regulating  the  Diet.  —  As  has  been  stated  in  a  former  chapter, 
any  persistent  loss  of  weight  or  failure  to  gain  on  the  part  of  an 
infant  whose  chief  business  in  life  should  be  to  grow,  should  be 
given  immediate  and  careful  attention.  As  a  rule  the  diet  is  to 
blame ;  it  is  either  improperly  balanced,  insufficient  in  amount, 
or  poorly  prepared,  any  of  which  might  readily  cause  a  disturbance 
to  the  delicate  apparatus  of  the  child. 

Diet  and  Habits.  —  In  adults,  the  diet  and  habits  of  life  are  in 
many  cases  to  blame  for  the  excessive  thinness  seen  in  many  in- 
dividuals. If  the  trouble  can  be  traced  to  some  abnormal  condi- 
tion, it  can  only  be  removed  by  relieving  or  checking  the  disease 
which  induced  it.  The  older  methods  of  treating  typhoid  fever, 
for  example,  did  nothing  to  prevent  the  progressive  emaciation 
which  was  the  result  not  only  of  the  accelerated  metabolism  from 
the  fever  but  also  from  the  invasion  of  the  intestinal  tract  by  the 
specific  bacteria  which  brought  about  a  like  result.  In  tuberculosis 
a  similar  breaking  down  of  the  tissues  occurs,  as  is  likewise  the 
case  in  anemia  and  other  diseases  in  which  the  functions  of  the 
blood-making  organs  are  interfered  with.  Any  of  the  above 
diseases  may  cause  emaciation,  and  the  treatment  in  most  of  the 
cases  resolves  itself  in  removing  the  cause  as  far  as  possible  and  in 
adjusting  the  diet. 

Selection  of  Food.  —  The  dietetic  treatment  for  emaciation  is 
practically  the  only  one  which  will  materially  change  the  weight  of 
the  individual,  since  by  food  alone  is  the  body  built.  Certain  foods 
are  more  capable  of  being  readily  converted  into  adipose  tissue  than 
others,  and  these  must  have  a  prominent  place  in  the  dietary. 

Rules  and  Regulations.  —  In  obesity  it  was  found  that  it  was 
necessary  to  curtail  the  sleep  and  rest,  increase  the  amount  of 
exercise  and  decrease  the  amount  of  food.     In  emaciation  practi- 


412  DIETETICS  FOR  NURSES 

cally  an  opposite  regime  is  adopted.  The  patient  is  urged  to  eat 
plenteously,  drink  copiously  of  water  and  nutrient  beverages, 
soup,  etc.,  avoid  worry  and  excitement,  over-exertion  and  in- 
digestion, to  take  one  or  two  naps  every  day,  to  retire  early,  to 
avoid  hot  baths  and  take  a  warm  cleansing  bath  followed  by  a 
cold  shower  or  sponge  bath.  Exercise  must  be  of  a  mild  character ; 
the  patient  must  be  warned  against  becoming  exhausted,  since  this 
condition  precludes  a  gain  in  weight. 

Dietetic  Treatment.  —  The  meals  must  be  carefully  selected, 
well  prepared  and  daintily  served,  that  all  of  the  psychical  benefits 
from  such  efforts  may  be  attained.  A  nutrient  beverage  such  as 
cream,  egg,  and  vichy,  reenforced  fruit  beverages,  malted  milk, 
with  egg  and  chocolate,  cereal  and  milk  gruels,  etc.,  may  be  given 
between  breakfast  and  lunch,  lunch  and  dinner  and  before  retiring. 
The  meals  must  consist  of  the  simplest  foods  that  the  digestional 
apparatus  may  riot  be  overtaxed  by  the  added  quantity  ingested. 

Allowable  Foods.  —  The  following  foods  may  be  used  in  the 
treatment  of  emaciation :  All  dairy  products,  milk,  cream,  butter 
and  cheese,  eggs  cooked  in  various  ways,  soups  of  all  kinds,  meats 
in  moderation,  vegetables,  especially  potatoes,  olive  oil,  and  the 
various  salad  oils,  cereals,  tapioca,  macaroni,  spaghetti,  noodles, 
rice,  bread  of  every  description,  fruit  including  bananas,  grapes, 
dates,  raisins,  prunes,  etc.,  ice  creams,  farinaceous  puddings,  sauces, 
except  those  containing  vinegar,  grape  juice  and  other  fruit  juices 
sweetened  with  sugar,  cocoa  and  chocolate,  malted  milk  and  pro- 
prietary infant  foods,  honey,  molasses  and  sirups,  cakes,  cookies 
and  pastry  in  moderation.  It  is  advisable  to  make  milk  the  chief 
fluid  food ;  to  this  is  added  cream,  malted  milk,  lactose,  eggs  and 
other  reenforcing  agents. 

Milk  Cure.  —  Certain  physicians  advise  milk  alone,  giving  from 
one  to  two  gallons  a  day  for  three  weeks  or  longer.  Many  in- 
dividuals complain  that  "  milk  makes  them  bilious  "  but  as  a  rule 
this  is  because  the  amount  taken  is  small  and  the  solids  insufficient 
to  lend  the  necessary  bulk  to  the  feces,  consequently  the  peristaltic 
action  becomes  sluggish  and  the  passage  of  the  food  mass  delayed 
in  the  intestinal  tract,  furnishing  a  medium  for  bacterial  growth  and 


GOUT,  OBESITY,  EMACIATION 


413 


activity.  When  larger  quantities  are  ingested  such  is  not  the  case 
and  the  fluid  so  high  in  nutrient  qualities  is  utilized  by  the  body  for 
the  building  up  of  the  depleted  tissues.  When  the  emaciation 
is  the  result  of  disease  the  diet  is  necessarily  adjusted  to  meet  the 
condition.  At  times  it  is  most  difficult  to  overcome  the  anemia 
and  accompanying  emaciation  on  account  of  the  disease  precluding 
the  giving  of  the  foods  especially  designed  by  nature  to  produce 
flesh.  This  is  especially  the  case  in  the  progressive  emaciation  in 
diabetes;  However,  in  this  case  the  Allen  starvation  treatment, 
with  the  reeducation  of  the  organs  to  a  toleration  for  carbohy- 
drates, has  gone  far  toward  overcoming  this  distressing  condition. 

Readjusting  the  Habits.  — When  the  loss  of  weight  is  found  to  be 
the  result  of  close  application  to  work,  lack  of  fresh  air  and  sleep, 
or  from  errors  in  diet,  a  change  of  climate  and  occupation  should 
be  made,  together  with  a  readjustment  of  the  daily  habits,  such  as 
substituting  a  cool  bath  for  the  regular  hot  one,  and  sleeping  out  of 
doors  or  on  a  sleeping  porch  instead  of  in  a  poorly  ventilated  bed- 
room. 

The  patient  must  be  urged  to  eat,  regardless  of  appetite,  for  in 
this  way  only  can  the  body  weight  be  increased.  The  dietary 
must  be  made  up  largely  of  the  fat-forming  foods,  but  not  to  such 
an  extent  as  to  upset  the  nitrogen  equilibrium. 

The  following  diet  sheet  is  given  to  be  used  as  a  guide  in  the 
treatment  of  emaciation.  Other  foods  of  a  similar  composition  and 
fuel  value  may  be  substituted  for  those  given  here,  to  vary  the  diet. 

EMACIATION   DIET  SHEET 

A-pproximately  5106  calories 


Material 

Amount 

Protein 
Gm. 

Carbohy- 
drate 
Gm. 

Fat 
Gm. 

Total 
Calories 

Breakfast : 

Stewed  prunes      .     . 

Sugar      ..... 

Oatmeal 

with  cream  and 
sugar  

6  prunes 
1  tbs. 

1  tbs.  (dry)    1 

2  tbs.  cream    • 
1  tbs.  sugar 

1.02 
3.2 

35.26 
14.7 

25.0 

6.6 

145. 
56.6 

172.2 

414 


DIETETICS  FOR  NURSES 


EMACIATION   DIET  SHEET  —  Continued 


Material 


Poached  egg     .     .     . 

Toast 

Butter 

Coffee 

with  cream  and 
sugar  

Milk  and  cream    .     . 

11  A.M. : 

Cereal  milk  gruel  . 
with  cream  .     .     . 

Lunch,  1  P.M. : 
Cream  of  pea  soup    . 
Potato  salad     .     .     . 

Bread 

Butter 

Cocoa     made     with 

milk 

Sugar      

Milk        

Cream 

3  :  30  P.M. :        ... 
Cream,  egg,  vichy     . 

Dinner : 

Tomato  bouillon  .     . 

with  whipped  cream 
Beefsteak    .... 
Mashed  potatoes 
Cauliflower       .     .     . 
Asparagus  salad  with 

mayonnaise .     .     . 

Bread      

Butter 

Charlotte  russe     .     . 
Milk  and     .... 

cream       .... 
Black  coffee  if  desired 

At  bed  time : 

Malted  milk  .  .  . 
made  with  milk 
and  reenf  orced  with 
lactose      .     .     .     . 


Amount 


1  egg 
3  slices 
1  tbs. 
1  cup 

1  tbs.  cream 

2  tsp. 

f  cup  milk 
I  cup  cream 

8  oz.  (1  cup) 
1  ounce 


8  oz.  (1  cup) 
3.5  oz.(l  serving) 
3  shces 
1  tbs. 


1  cup 

2  tsp. 
f  cup 
i  cup 

8oz. 


1  cup 

1  tbs. 

1  serving  (3  oz.) 

3  cup 

1  serving 
6  stalks 

2  tsp. 
2  slices 
2  tbs. 

1  serving 
f  cup 
i  cup 
h  cup 


1  cup 


1  ounce 


Protein 
Gm. 

Carbohy- 
drate 
Gm. 

Fat 
Gm. 

5.35 

4.16 

7.9 

44.7 

13.0 

.40 

.40 
9.45 

2.8 

6. 
1.75 

7.8 
.8 

17.65 
15.5 

44.7 
1.4 

7.66 
15.33 
1.041 
5.6  J 

27. 

27.6 

41.4 

4.9 

12.4 

36. 

.30 

18.6 

1.16 

1.53 

2.00 

.01 
5.2 

.28 
2.3 

.42 

7.5 
2.99 
3.72 
1.45 
29.8 

11.1 

5.67 

17.34 

3.5 

.42 

.241 

9.00] 

.681 

24.09/ 

22.6 

8.4 

41. 

10.2 

Total 
Calories 

58.8 
328. 

53.9 

389. 

248. 

185.9 
210. 

328. 

661. 
329. 

393. 

38. 
53.9 
230.5 
66.5 
21.8 

111.8 

419. 
257. 
389. 


288.5 


GOUT,  OBESITY,  EMACIATION  415 

Methods  of  Increasing  the  Diet.  —  The  above  diet  furnishes 
three  times  as  much  food  as  is  needed  to  maintain  the  body 
Hving  a  sedentary  life,  or  about  as  much  as  would  be  needed  to 
maintain  a  lumberman  at  hard  outdoor  labor  in  the  Maine  woods. 
It  would  be  impossible  for  an  ordinary  individual  to  handle  such 
an  abundant  diet  without  making  the  increase  in  the  diet  gradually. 
This  is  best  done  by  adding  the  milk  and  cream  at  the  end  of 
each  meal  and  a  glass  of  milk  between  meals  and  at  bedtime,  then 
gradually  adding  the  fattening  foods  already  mentioned  until  the 
diet  approximates  the  diet  sheet  here  computed. 


SUMMARY 
GOUT 

Gout  is  a  constitutional  disease  characterized  by  an  inflammatory 
condition  of  the  joints. 

The  Joints  are  the  seat  of  chalky  deposits  of  uric  acid  or 
sodium  salts. 

Metabolism  in  gout  is  disturbed,  with  a  consequent  retention 
instead  of  elimination  of  uric  acid  by  the  body. 

The  Blood  contains  an  excess  of  uric  acid  which  increases 
greatly  during  an  acute  attack. 

The  Urine  in  true  gout  does  not  contain  an  excess  of  uric 
acid  except  during  an  acute  attack,  whereas  in  the  so-called  gouti- 
ness there  is  a  constant  excess  of  this  acid. 

Uric  Acid  is  produced  as  the  result  of  the  metabolism  in  the 
human  body  of  the  nucleoproteins  and  in  food  of  the  purin 
bodies. 

Alcohol  undoubtedly  assists  in  the  retention  and  increases  the 
difficulty  of  uric  acid  elimination  by  the  body. 

Chief  Causes  of  Gout.  —  Overeating,  excessive  alcoholism,  and 
too  little  exercise,  especially  in  the  open  air. 

Treatment  consists  in  regulating  the  diet  both  as  to  the  quan- 
tity and  type  of  food  eaten ;  reducing  or  eliminating  the  alcohol 
in  the  dietary,  and  increasing  the  amount  of  outdoor  exercise. 


416  DIETETICS  FOR  NURSES 

Dietetic  Treatment.  —  The  best  results  are  obtained  by  reducing 
the  size  of  the  meals  and  avoiding  the  purin-bearing  foods  as  far 
as  possible.  Eggs  are  purin-free  and  may  be  substituted  for 
much  of  the  meat  in  the  diet.  In  chronic  gout  it  is  impossible  to 
eliminate  meat  entirely  from  the  diet,  but  the  quantity  can  be 
materially  reduced  and  that  which  is  eaten  may  be  rendered  less 
harmful  if  it  is  boiled  instead  of  roasted  or  broiled,  as  in  this  way 
much  of  the  pur  ins  is  dissolved  out.  Highly  spiced  and  seasoned 
foods,  rich  gravies,  etc.,  are  apt  to  cause  an  acute  attack  and  should 
be  omitted.  Excesses  of  all  kinds  must  be  avoided  to  enable  the 
patient  to  live  a  fairly  comfortable  life,  free  from  frequent  painful 
attacks  of  gout. 


OBESITY 

Causes.  —  Heredity,  overeating,  unbalanced  diet,  chronic 
alcoholism,  and  disturbed  metabolism,  as  manifested  in  gout  and 
other  pathological  conditions. 

Cures  are  more  or  less  of  a  risk,  except  when  undertaken 
upon  the  advice  and  under  the  care  of  a  competent  physician. 
As  a  rule  they  are  too  strenuous  to  be  carried  out  alone  and  are  of  no 
good  unless  persisted  in.  Among  the  best  known  obesity  cures 
may  be  mentioned  those  formulated  by  Banting,  Oertel  and 
Ebstein. 

Most  physicians  have  their  own  methods  of  treating  obesity, 
but  all  are  based  primarily  on  diet  and  exercise. 

Food  is  the  chief  cause  of  obesity  and  since  some  foods  are 
more  readily  converted  into  adipose  tissue  than  others,  it  is 
necessary  to  understand  the  behavior  and  functions  of  the  various 
food  combinations  in  the  body  before  it  is  possible  to  say  which 
are  the  offending  articles  of  diet. 

Water  has  no  fattening  properties  of  its  own.  This  is  proved 
by  a  glance  at  its  chemical  composition,  but  as  it  acts  as  a 
distributer  and  carrier  of  food  to  the  various  parts  of  the  body  and 
since  the  bulk  of  all  the  secretions  is  composed  of  water  and  every 
tissue  in  the  body  stores  this  fluid,  thus  adding  to  the  weight,  a 


GOUT,  OBESITY,  EMACIATION  417 

consideration  of  the  intake  of  water  for  obesity  patients  is  most 
essential. 

Appetite  requires  attention.  The  majority  of  obese  patients 
eat  more  than  their  energy  output  calls  for,  consequently  it  js 
necessary  to  curb  the  appetite  and  increase  the  energy  output  in 
order  to  utilize  the  material  on  hand  in  the  form  of  adipose  tissue-. 

Exercise  is  absolutely  essential  in  order  to  force  the  body  to 
burn  up  its  surplus  fat  as  fuel.  The  best  form  of  exercise  is  that 
which  is  taken  out  of  doors.  The  well-worked  muscle  is  heavier 
than  one  which  is  unaccustomed  to  exercise.  The  latter  is  in- 
filtrated with  fat  and  weighs  less  than  muscular  tissue,  but  a 
muscular  body  can  endure  more  than  one  which  is  covered  with 
adipose  tissue. 

The  Heart  of  obese  patients  becomes  more  or  less  affected 
as  obesity  advances  and  it  becomes  absolutely  necessary  in  many 
cases  to  get  rid  of  some  of  the  surplus  fat  in  order  that  the  patient 
may  live.    This  is  best  accomplished  by  dietetic  treatment. 

Circulatory  Changes  Hkewise  occur  as  the  heart  becomes 
affected,  making  it  necessary  to  institute  some  dietary  measures 
at  once. 

Glycosuria  in  obese  patients  suffering  from  gout  is  not  at 
all  unusual  and  to  relieve  this  condition  the  carbohydrates  in  the 
diet  must  be  at  once  reduced. 

Dietetic  Treatment  is  most  important.  It  constitutes  the 
only  rational  method  of  ridding  the  body  of  its  surplus  fat.  To  do 
this  it  is  necessary  to  regulate  the  diet  both  as  to  quantity  and 
type.  Fat-forming  foods  are  those  which  the  body  utilizes  most 
easily  for  the  production  and  storage  of  fat.  Any  food,  no  matter 
whether  it  is  fat-forming  or  not,  if  taken  greatly  in  excess  of  the 
needs  of  the  body,  will  be  stored  as  adipose  tissue. 

Chief  Points  to  be  remembered  in  formulating  a  diet  and  in- 
stituting an  obesity  treatment  are  the  necessity  for  small  vieals 
and  dry  meals,  no  fluid  given  at  all  during  the  meal  except  perhaps 
one  or  two  small  cups  of  coffee  per  day,  without  sugar  or  cream, 
the  avoidance  of  fat-forming  foods,  sugars  and  starches  in  all 
forms,  milk,  cream,  butter  and  oil,  potatoes,  bananas,  fat  meats 
2e 


418  DIETETICS  FOR  NURSES 

of  all  descriptions,  especially  pork,  soups  of  every  description  and 
alcoholic  or  malted  beverages.  It  is  necessary  to  limit  the  amount 
of  sleep,  prohibiting  naps  during  the  day,  and  to  increase  the 
amount  of  outdoor  exercise. 

Massage  is  advisable,  especially  in  those  patients  who  are 
unable,  on  account  of  their  excessive  weight  or  heart  symptoms, 
to  take  the  requisite  amount  of  exercise  necessary  for  their  future 
welfare.  Massage  likewise  makes  the  muscles  firmer,  often  pre- 
venting the  disfiguring  sagging  of  the  skin  caused  by  depriving  it 
of  its  padding  of  fat. 

EMACIATION 

Causes.  —  Errors  in  diet,  overwork,  over-exercise,  heredity, 
nervousness,  worry,  malformation  of  the  mouth,  throat,  or  stomach, 
heredity  and  certain  pathological  conditions,  such  as  typhoid  fever, 
tuberculosis,  anemia,  dysentery,  etc.,  in  which  the  breaking  down 
of  the  tissues  occurs  more  rapidly  than  they  can  be  rebuilt. 

Children  are  often  emaciated  on  account  of  their  unbalanced 
diet.  They  receive  an  insufficient  amount  of  building  food  to 
cover  their  growth  and  development  requirements.  Parents  are 
often  to  blame  for  allowing  the  child  to  overeat  of  some  of  the 
food  constituents  at  the  expense  of  others.  Sugar,  for  example, 
is  very  necessary  in  the  diet  of  a  growing  active  child,  but  all  sugar 
and  very  little  milk  and  eggs  will  lead  to  an  unbalanced  diet  which 
may  bring  about  a  condition  of  extreme  thinness  later  on. 

In  Adults  the  constant  eating  of  the  wrong  foods,  overwork- 
ing and  persistent  worrying,  all  contribute  to  the  breaking  down  of 
the  tissues  which  ends  in  emaciation. 

Weight  is  an  index  to  health.  Any  persistent  loss  of  weight 
on  the  part  of  an  adult  or  loss  or  even  failure  to  gain  in  a  grow- 
ing child,  are  indications  that  all  is  not  right  and  immediate 
measures  must  be  taken  to  locate  and  relieve  the  trouble. 

Loss  of  Weight  due  to  pathological  conditions  can  only  be 
relieved  by  removing  the  cause,  after  which  the  diet  may  be  ad- 
justed to  suit  the  condition. 


GOUT,  OBESITY,  EMACIATION  419 

Dietetic  Treatment  is  practically  the  only  means  of  com- 
bating and  overcoming  emaciation,  since  it  is  by  food  alone  that 
the  body  is  built. 

Fat-forming  foods,  which  in  obesity  were  prohibited,  have  a 
prominent  place  in  the  diet  for  emaciation.  Padding  the  nerves 
and  organs  with  a  layer  or  covering  of  fat  protects  them  from  the 
jars  and  shocks  incidental  to  daily  life,  besides  lending  grace  and 
contour  to  the  body. 

Foods  Which  Produce  Fat  are  nutrient  beverages  of  all  sorts ; 
milk,  malted  milk  and  cream  are  especially  valuable ;  water, 
because  of  its  particular  properties  and  functions  in  the  body ; 
and  fruit  beverages,  which  are  made  chiefly  of  water*  and  sugar, 
are  always  included  in  the  dietary.  Milk  and  cream,  soups  and 
milk  gruels,  as  well  as  all  dishes  made  with  milk  or  cream,  add 
materially  to  the  fat-forming  quality  of  the  diet.  Butter,  olive 
and  other  salad  oils,  as  well  as  cereaH,  potatoes,  bread  and  simple 
desserts,  are  advised.  The  diet  must  be  bountiful,  the  meals 
frequent,  and  lunches  consisting  of  milk  or  cream  with  crackers 
will  hasten  the  gain  in  weight. 

Rest,  preferably  lying  down,  is  absolutely  essential.  A  period 
of  relaxation  covering  from  fifteen  to  thirty  minutes  should  be 
taken  before  or  after  each  meal.  The  body  derives  the  use  of  the 
food  for  the  storage  of  fat  which  would  otherwise  be  required  to 
cover  its  energy  expenditures. 

Sleep  is  essential  to  gain,  consequently  the  patient  should 
retire  early  and  take  one  or  tv/o  naps  during  the  day. 

Baths  should  be  warm,  not  hot,  followed  by  a  cold  shower  or 
sponge. 

Exercise  must  be  mild  in  character;  over-exertion  precludes 
a  gain  in  weight  and  exhaustion  undermines  the  forces  which  make 
it  possible  for  the  body  to  store  fat  as  adipose  tissue. 

Nervous  Excitement  and  Worry  must  be  avoided. 

Gastro-intestinal  Disturbances  should  be  guarded  against, 
since  all  the  pounds  gained  through  months  of  treatment  may 
be  quickly  lost  during  one  acute  attack  of  diarrhea  or  auto- 
intoxication. 


420  DIETETICS  FOR  NURSES 

Massage  is  advised.  The  kneading  and  gentle  manipula- 
tion of  the  muscles  stimulates  them  to  utilize  more  food  material, 
besides  enabling  the  patient  to  eat  more  by  reason  of  an  increased 
appetite. 

The  Milk  Cure  has  been  used  extensively  in  overcoming  extreme 
emaciation.  It  consists  in  the  taking  of  large  quantities,  ranging 
from  one  to  two  gallons  per  day.  It  is  given  every  hour  or 
oftener  for  a  period  of  one  month  to  six  weeks. 

Reenforcing  the  Diet  with  eggs  and  lactose  is  often  found  of 
great  value  in  increasing  the  weight  quickly,  as  is  the  giving  of 
one-third  of  a  glass  of  cream  and  two-thirds  of  a  glass  of  milk  after 
each  meal  Und  at  bedtime.  The  whole  scheme  of  putting  on 
pounds  resolves  itself  into  the  giving  of  proper  food  in  larger 
quantities  than  are  ordinarily  given,  but  dividing  it  up  into 
frequent  meals  in  order  not  to  upset  the  digestion  and  do  away  with 
the  good  already  accomplished. 


CHAPTER  XXV 

OTHER  CONDITIONS  MORE  OR  LESS  AFFECTED  BY 

DIET 

PTOMAINE   POISONING,    ACIDOSIS   AND   PELLAGRA 
PTOMAINE   POISONING 

The  poisoning  due  to  ptomaine  is  very  similar  to  that  brought 
about  by  overeating  and  other  dietetic  errors.  However,  it  is  not 
so  easy  to  avoid  being  poisoned  by  ptomaines  as  it  is  to  observe 
moderation  in  the  quantity  of  food  eaten. 

Origin.  —  These  substances  are  believed  to  be  of  an  infective 
bacterial  origin  and  may  be  present  in  foods  which  are  otherwise 
seemingly  fresh  and  good.  The  fact  that  they  cannot  be  detected 
in  food  without  an  analysis  makes  them  more  of  a  menace  than  they 
would  otherwise  be,  for  any  substance  which  is  not  discernible  to 
our  senses,  the  taste,  sight,  or  smell,  and  which  exerts  a  baleful 
influence,  such  as  ptomaine,  cannot  be  anything  but  a  menace  to 
humanity. 

Infected  Food  Materials.  —  We  may  congratulate  ourselves  in 
the  knowledge  that  these  substances  are  not  present  in  many 
foods,  and  if  we  avoid  eating  nitrogenous  materials,  which  may 
have  become  polluted,  either  through  imperfect  canning  or  by 
standing  in  unclean  vessels,  we  may  avoid  much  of  the  poison- 
ing which  may  otherwise  be  due  to  the  action  of  ptomaines. 

Chicken  Salad  and  Ice  Cream  Poisoning.  —  Certain  violent 
attacks  of  so-called  ptomaine  poisoning  may  be  traced  to  chicken 
salad  which  has  been  allowed  to  stand  overnight  in  tin  receptacles 
or  to  ice  cream  which  has  melted  and  been  re-frozen.  In  any  case 
the  treatment  remains  the  same. 

Treatment.  —  The  patient  is  put  to  bed  and  the  intestinal  tract 
cleansed  by  means  of  enemas  and  in  many  cases  purgatives  (salts, 
castor  oil,  etc.)  as  directed  by  physician. 

421 


422  DIETETICS  FOR  NURSES 

The  symptoms  usually  present  in  those  suffering  from  ptomaine 
poisoning  are  nausea,  vomiting,  dizziness,  pain  more  or  less  violent 
in  character,  and  prostration  which  is  at  times  alarming. 

Dietetic  Treatment.  —  The  treatment  instituted  under  the 
circumstances  is  very  much  the  same  as  that  used  in  other  forms 
of  acute  poisoning.  All  food  is  withheld  for  a  period ;  the  duration 
of  this  starvation  must  necessarily  depend  upon  the  condition  of 
the  patient,  the  violence  of  the  poison  and  the  extent  of  the  pros- 
tration. 

Rectal  Feeding.  —  When  the  prostration  is  great,  it  is  some- 
times necessary  to  give  saline  enemas  and  even  rectal  alimenta- 
tion to  prevent  collapse. 

Fluid  Diet.  —  After  the  violent  attack  subsides,  the  patient  is 
placed  upon  a  fluid  diet  similar  to  that  used  in  auto-intoxication 
and  practically  the  same  as  the  diet  for  acute  infectious  diseases. 
The  diet  must  be  gradually  increased  until  it  becomes  normal  and 
the  nurse  must  remember  that  the  patient  is  in  a  condition  to  suffer 
a  relapse  with  the  least  indiscretion.  It  is  advisable  to  have  a 
thorough  investigation  made  to  ascertain  the  source  of  the  original 
attack,  that  the  patient  may  be  able  to  avoid  future  trouble  from 
partaking  of  the  same  food. 

Personal  Idiosyncrasies.  —  It  may  be  that  there  is  a  personal 
idiosyncrasy  against  one  particular  food,  and  in  this  case  it  becomes 
more  or  less  of  a  simple  matter  to  prevent  future  attacks.  Certain 
individuals  are,  for  example,  invariably  poisoned  by  eating  shell- 
fish, others  manifest  a  similar  idiosyncrasy  against  strawberries. 
Thus  is  the  old  proverb  demonstrated :  "  What  is  one  man's 
meat  is  another  man's  poison."  And  he  who  wantonly  flies  in 
the  face  of  the  danger  signals  Nature  provides  for  his  guidance 
must  necessarily  suffer  the  consequences  of  his  folly. 

It  has  been  proved  with  certain  individuals  that  the  foods  that 
at  one  time  cause  an  attack  of  poison  at  another  time  may  be  eaten 
with  impunity.  Thus  it  would  seem  to  remain  a  question  not  so 
much  of  the  type  of  poison,  ptomaines,  etc.,  as  the  amount  of  re- 
sistance manifested  at  the  time  by  the  individual  partaking  of  the 
infected  food. 


OTHER  CONDITIONS  AFFECTED  BY  DIET      423 

Acroosis 

Metabolism  of  Fats.  —  Acidosis  is  a  condition  believed  to  be 
due  primarily  to  some  impairment  in  the  metabolism  of  fat  in 
the  body,  in  consequence  of  which  there  is  an  accumulation  of 
substances  more  or  less  irritating  and  at  times  toxic  in  character 
in  the  blood.  These  substances,  known  as  acetone  bodies,  are 
especially  apt  to  appear  in  the  urine  of  individuals  suffering  from 
diabetes,  likewise  in  those  undergoing  starvation,  whether  as  a 
result  of  treatment  to  overcome  a  definite  pathological  condition, 
as  in  diabetes,  or  as  the  result  of  disease  itself. 

Malnutrition  as  a  Source.  —  Certain  individuals,  ohildren 
especially,  develop  symptoms  of  acidosis  under  many  different 
circumstances ;  for  example,  in  many  cases  of  malnutrition  the 
evidences  of  acidosis  are  almost  invariable.  The  treatment  in 
these  cases  must  be,  of  course,  prompt  in  order  that  the  condition 
may  not  assume  a  serious  aspect. 

Dietetic  Treatment.  —  The  diet  is  adjusted  in  order  to  neutralize 
the  effect  of  the  acid  in  the  blood.  This  is  done  in  two  ways : 
first,  by  reducing  the  fat,  and  second,  by  increasing  the  amount 
of  base-forming  foods  in  the  diet. 

The  following  table  ^  illustrates  the  foods  in  which  the  acid- 
forming  elements  and  base-forming  elements  predominate : 


FOODS  IN  WHICH  ACID-FORMING  ELEMENTS 
PREDOMINATE 

Estimated  Excess  Acid-forming  Elements  Equivalent  to  C.C.  Normal  Acid 

per  100  Calories 

Beef,  free  from  visible  fat 10 

Eggs 9 

Round  steak 6.7 

Oatmeal 3.2 

Wheat  flom- 2.7 

Wheat,  entire  grain • 2.6 

Rice 2.4 

Bacon 1 

Corn,  entire  grain  (high  protein) 1 

1  "  Chemistry  of  Food  and  Nutrition,"  by  Henry  Sherman. 


424  DIETETICS  FOR  NURSES 

FOODS    IN   WHICH   BASE-FORMING   ELEMENTS 
PREDOMINATE 

Estimated  Excess  Base-forming  Elements  Equivalent  to  C.C.  Normal  Alkali 

per  100  Calories 

Celery 40 

Cabbage 10-13.6 

Potatoes 9-12 

Prunes 7.9 

Turnips ' 6.6-12.5 

Apples 5 

Milk 3.3 

Beans 2.9-6.8 

Peas 1.9 

Corn,  entire  grain  (low  protein) 8 

The  fruits  likewise  show  a  predominance  of  base-forming  ele- 
ments over  acid-forming  elements  and  for  this  reason  may  be  used 
to  balance  the  diet. 

Diabetic  Acidosis.  —  The  acidosis  during  diabetes  has  been 
already  discussed  in  the  chapter  devoted  to  that  disease. 

It  has  been  found  advisable  in  the  majority  of  cases  of  acidosis 
to  restrict  the  fat  in  the  diet  of  all  patients  who,  during  the 
course  of  a  disease,  have  given  evidence  of  this  condition ;  at  the 
same  time  it  is  well  to  remember  that  fat  is  one  of  the  essential 
food  constituents  and  absolutely  necessary  to  the  welfare  of  the 
individual,  consequently  it  is  impossible  to  eliminate  it  from  the 
diet  entirely.  The  only  feasible  method,  then,  to  pursue  under 
the  circumstances  is  to  restrict  the  fats  in  the  diet  so  long  as  there 
are  symptoms  of  acidosis  and  to  add  them  gradually  and  in  very 
small  amounts  until  the  individual's  tolerance  for  fats  is.  deter- 
mined. 

Balancing  the  Diet.  —  In  many  cases  of  acidosis  due  to  starva- 
tion, no  matter  what  the  cause,  the  diet  must  be  necessarily  regu- 
lated and  properly  balanced.  It  would  be  decidedly  unwise  to 
attempt  to  build  up  the  body  by  giving  building  foods  alone, 
without  due  consideration  to  the  foods  containing  the  agents 
provided  by  Nature  to  neutralize  the  acid  formed  during  the  pro- 
cess of  their  metabolism.  It  is  readily  seen  in  the  table  just 
given  that  meat  and  eggs  show  a  marked  excess  of  acid-forming 


OTHER  CONDITIONS  AFFECTED  BY  DIET     425 

elements,  whereas  vegetables  and  fruits  yield  an  excess  of  base- 
forming  elements.  With  this  data,  it  becomes  more  simple  to 
balance  the  diet  and  to  avoid  the  acidosis  which  may  arise  from 
impairment  of  the  fat  metabolism  of  the  body. 

PELLAGRA 

The  enormous  increase  in  the  number  of  cases  of  pellagra  in 
America  during  the  last  twenty  years  makes  it  necessary  for  some- 
thing to  be  done  to  arrest  its  progress.  The  cause  of  this  disease 
is  still  under  discussion,  but  much  has  been  done  to  find  out 
definitely  the  reason  for  the  tremendous  increase  in  the  number 
of  cases,  especially  in  the  Southern  States,  where  the  increase  has 
been  most  noticeable. 

Infectious  Bacteria,  Silicon,  and  Lack  of  Vitamines.  —  Many 
investigators  believe  the  disease  to  be  caused  by  the  ingestion  of 
certain  foods  infected  by  the  action  of  a  definite  type  of  bacteria, 
while  others  believe  it  to  be  induced  by  the  drinking  of  water 
impregnated  by  colloidal  silicon.  Still  other  scientists  claim 
that  pellagra  is  the  direct  result  of  an  unbalanced  diet,  especially 
one  in  which  the  vitamines  are  noticeably  lacking. 

Nutrition  in  Pellagra.  —  At  present  we  cannot  say  positively 
that  pellagra  is  a  nutritional  disease  any  more  than  we  can  say 
that  tuberculosis  is  a  nutritional  disease.  We  only  know  that 
diet  undoubtedly  plays  an  important  part  in  the  relief  of  each  of 
these  conditions,  and  to  this  end  we  must  direct  our  efforts. 

Dietetic  Treatment.  —  The  diet  for  pellagra  must  necessarily 
be  such  as  to  overcome  as  far  as  possible  the  progressive  emaciation 
which  is  an  important  symptom  in  the  disease.  However,  it  must 
be  kept  in  mind  that  gastro-intestinal  disturbances  are  likewise 
prominent  and  that  diarrhea  is  often  most  difiicult  to  overcome. 
For  these  reasons  it  is  essential  to  formulate  a  diet  which  will  not 
interfere  with  the  treatment  for  the  disease,  and  which  will  be  at 
the  same  time  one  in  which  the  patient  can  gradually,  be  built 
up,  and  in  this  way  benefit,  as  far  as  possible,  under  the  cir- 
cumstances. The  diet  used  in  the  treatment  of  anemia  seems  to 
be  the  one  best  suited  to  meet  the  requirements  of  the  patient 


426  DIETETICS  FOR  NURSES 

suffering  with  pellagra ;  changes  may  be  made  in  this  diet,  however, 
by  the  physician,  who  will  be  able  to  judge  the  need  of  the  in- 
dividual under  his  care.  Whether  pellagra  can  be  cured  by  dietetic 
treatment  is  very  uncertain,  but  the  condition  of  the  patient  can 
undoubtedly  be  materially  improved,  provided  the  treatment  is 
begun  suflBciently  early ;  that  is,  before  the  disease  has  progressed 
to  such  an  extent  that  neither  diet  nor  anything  else  can  bring 
about  a  cure. 

The  above  dietetic  treatment  is  not  claimed  to  be  infallible.  It 
is  merely  given  as  a  suggestion  to  be  used  at  the  discretion  of  the 
physician. 

In  all  probability  the  treatment  of  pellagra  will  undergo  a  definite 
change  in  the  near  future,  but  at  present  our  best  results  accrue 
from  the  giving  of  an  adequate,  well-balanced  diet.  The  extent 
of  the  relief  of  such  dietetic  measures  depends,  as  has  already  been 
stated,  upon  taking  the  disease  in  its  early  stage. 

SUMMARY 

Food  Poisoning  is  more  or  less  common,  being  induced  by 
polluted  water,  milk,  or  other  foods,  bad  sanitation,  and  imperfect 
canning,  as  well  as  to  certain  obscure  substances  known  as  pto- 
maines. 

Shellfish  have  often  been  found  to  cause  poisoning  in  certain 
individuals.  Stale  fish  is  apt  to  cause  the  most  violent  type  of 
poisoning  in  any  individual. 

Chicken  Salad  which  has  been  kept  overnight  in  tin  re- 
ceptacles has  been  known  to  cause  violent  attacks  of  poisoning. 

Ice  Cream  which  is  melted  and  re-frozen  is  likewise  a  source  of 
a  number  of  the  cases  reported. 

Symptoms.  —  Very  like  those  of  auto-intoxication,  and  violent 
intestinal  disturbances  are  manifested. 

Prostration  is  apt  to  be  great,  according  to  the  violence  and 
duration  of  the  attack. 

Anemia  follows  many  cases  of  poisoning  as  a  result  not  only 
of  the  impairment    and  lack  of   nutrition  of  the  blood-making 


OTHER  CONDITIONS  AFFECTED  BY  DIET     427 

organs,  but  also  on  account  of  the  other  symptoms,  especially 
diarrhea  occurring  in  the  disease. 

Dietetic  Treatment  like  that  used  in  acute  gastro-intestinal 
disturbances  begins  with  a  starvation  period  and  is  followed  by 
a  simple  fluid  diet  until  violent  symptoms  subside.  Examination 
of  the  stools  and  the  material  vomited  will,  at  times,  furnish  an 
insight  as  to  the  source  of  the  poison. 

Convalescent  Diet  is  begun  after  the  violent  symptoms  have 
subsided,  but  care  must  be  taken  not  to  increase  the  diet  too 
rapidly,  owing  to  the  danger  from  relapse. 

Method  of  Administering  Diet.  —  First :  a  period  of  total 
abstinence  from  food. 

Second :  fluid  diet  consisting  of  broth,  buttermilk,  or  some  of 
the  predigested  liquid  beef  preparations  which  furnish  both  food 
and  stimulation  necessary  in  such  cases. 

Rectal  Feeding  may  be  found  necessary  when  the  prostration 
is  great. 

Personal  Idiosyncrasies  should  be  taken  into  account  and 
effort  made  to  find  whether  or  not  the  attack  is  caused  by  any 
one  food  material  or  to  bad  sanitation  or  unclean  food.  The 
patient  should  be  warned  against  the  danger  of  taking  a  food  which 
has  caused  a  previous  attack  of  poisoning,  especially  in  cases 
where  a  personal  idiosyncrasy  against  a  food  has  been  manifested. 

Resistance  of  Poison  in  food  seems  to  be  the  chief  thing. 
The  strength  and  vigor  of  a  body  lends  resistance  and  assists 
materially  in  combating  bacterial  activities.  Thus  if  ptomaines 
are  of  bacterial  origin,  as  many  investigators  believe  them  to  be, 
the  safest  plan  is  to  keep  the  physical  condition  good  and  in  this 
way  prevent  their  getting  a  hold  on  the  body. 

Other  Precautions  against  ptomaine  and  other  food  poison- 
ing. Patients  are  recommended  to  eat  no  food  which  has  been 
carelessly  handled,  kept  in  unclean  receptacles,  improperly  canned, 
or  allowed  to  stand  in  tin  for  any  length  of  time. 


428  DIETETICS  FOR  NURSES 

ACIDOSIS 

This  condition  is  more  or  less  common,  especially  in  the  dis- 
turbances manifested  by  children. 

Cause  of  acidosis  is  believed  to  be  an  impairment  of  metab- 
olism, especially  in  regard  to  the  fats. 

Starvation  or  Malnutrition  is  believed  to  produce  many  cases 
of  acidosis  in  childhood  and  adults  suffering  from  diseases  in 
which  certain  foods  have  been  limited. 

Diabetes  in  which  there  is  an  impairment  in  the  metabolism 
of  carbohydrates,  resulting  in  the  unavailableness  of  these  foods 
as  neutralizing  agents  of  the  acids  formed  in  the  body,  is  one  of 
the  chief  diseases  in  which  acidosis  develops  and  in  which  the  results 
are  so  apt  to  be  fatal. 

Dietetic  Treatment  consists  chiefly  in  limiting  the  fats  in  the 
diet  and  increasing  the  amount  of  neutralizing  agents  in  the 
food. 

Alkalies  are  at  times  given  when  acidosis  is  prominent,  but 
these  substances,  other  than  those  occurring  in  foods,  must  be 
given  only  upon  the  advice  of  a  physician. 

Conclusion.  —  As  to  the  relief  of  acidosis,  everything  points  to 
the  advisability  of  balancing  the  diet  both  as  a  means  of  preventing 
and  overcoming  the  condition.  Even  when  acidosis  is  a  symptom 
of  starvation  it  is  not  wise  to  increase  the  building  foods  materially 
without  allowing  a  certain  amount  of  base-forming  or  neutralizing 
material  to  offset  the  increased  production  of  acid  in  the  body. 

PELLAGRA 

The  cause  and  cure  for  this  disease  are  still  a  matter  of  discussion. 
Whether  it  is  the  result  of  a  definite  bacterial  infection  or  whether 
it  is  due  to  the  presence  or  absence  of  certain  substances  in  the 
food  materials,  is  as  yet  to  be  determined. 

Diet  in  Pellagra  is  most  important.  It  is  impossible  to  say 
that  pellagra  is  a  nutritional  disease,  but  it  is  certain  that  in 
balancing  the  diet  much  has  been  done  toward  relieving  the  con- 
dition. 


OTHER  CONDITIONS  AFFECTED  BY  DIET     429 

The  Diet  is  directed  toward  overcoming  the  progressive 
emaciation  which  is  a  prominent  feature  in  the  disease  in  its 
advanced  stages,  and  toward  preventing  gastro-intestinal  dis- 
turbances. 

Diarrhea  is  one  of  the  chief  symptoms  of  the  disease  and 
great  care  is  needed  in  formulating  the  dietary  in  order  not  to 
increase  this  condition. 

Conclusion.  —  The  diet  is  thus  shown  to  be  directed  toward 
overcoming  the  emaciation  and  anemia  and  relieving  or  preventing 
the  gastro-intestinal  disturbances  which  are  so  apt  to  occur.  It 
must  be  remembered  that  even  a  well-balanced  diet  will  not 
materially  relieve  the  condition  unless  it  is  instituted  sufficiently 
early. 


INDEX 


Absorption,  118 

defined, 110 

in  large  intestine,  120 

of  carbohydrate,  119 

of  fat,  119 

of- mineral  salts,  120 

of  proteins,  119 

of  water,  120 
Acetone  bodies,  in  diabetes,  361 
Acetone  in  urine,  test  for,  360 
Acid,  butyric,  10 

oleic,  11 

palmitic,  10 

stearic,  11 

uric,  299 
Acid-forming  foods,  129,  423. 
Acidosis,  423,  424,  428 

dietetic  treatment  of,  423,  428 

in  diabetes  mellitus,  338,  345,  361 

in  typhoid  fever,  271 
Acids,  amino,  13 
Added  urea  and  salt  test,  319 
Adenase,  114 
Adenin,  127 

Adulterants,  tests  for,  37 
Adulteration  of  food,  36 
Age,  influence  of,  on  food  requirements, 

134,  139 
Albumen,  in  urine,  302 

tests  for,  302 
Albumenized  grape  juice,  preparation  of, 
67 

lemonade,  preparation  of,  66 

milk,  preparation  of,  63 

milk  shake,  preparation  of,  65 

orangeade,  preparation  of,  66 
Albumens,  13 
Albuminoids,  14 
Albuminuria,  302 

of  pregnancy,  diet  in,  ''.64 
Alcohol  in  gout,  392 
Alkalies  in  diabetes  mellitus,  345 

in  infant  feeding,  172,  173 
Alkaline  carbonates,  effect  of,  on  gastric 

secretion,  121 
Allen's  Paradoxical  Law,  337 

starvation  treatment  in  diabetes,  59, 
338,  361 


Almond  biscuits,  preparation  of,  79,  374 
Almond  cakes,  preparation  of,  80 
Almond  ice  cream,  preparation  of,  102 
Almonds,  composition  and  fuel  value  of, 

144 
Amino  acids,  13 
Ammonium  salts,  126 
Amylopsin,  114,  117 
Angel  food  cake,  preparation  of,  103 
Animal  proteins,  4 
Antiscorbutic  foods,  201,  208 
Appendicitis,  248,  256 

convalescent  diet  in,  248,  257 

dietetic  treatment  in,  248,  256 
after  operation,  293,  297 

food  to  be  provided  in,  249 

recurring,  257 

relapse  in,  257 
Apples,  ash  constituent  of,  16 

composition  and  fuel  value  of,  144 
Apple  tapioca  pudding,  preparation  of, 

94 
Apricot  ice,  preparation  of,  101 
Arrowroot,  composition  and  fuel  value 

of,  144 
Artificial  feeding  of  infants,  172 
Artificially    fed    infants,    digestive    dis- 
turbances in,  191 
Ash  constituents  of  foods,  15,  16,  17 
Asparagus,  ash  constituent  of,  16 

composition  and  fuel  value  of,  144 
Assimilation  defined,  110 
At  water's  dietary,  131,  132 
Auto-intoxication,  252 

absorption  of  toxins  in,  252 

care  of  bowels  in,  253 

convalescent  diet  in,  253 

dietetic  treatment  of,  253 

Bacon,  31 

composition  and  fuel  value  of,  144 

preparation  of,  85 
Bacteria,  action  of,  in  alimentary  canal, 
122 

types  of,  123 
Bacterial  action  in  body,  124 

activity,  210 
Baked  custard,  preparation  of,  92 


431 


432 


INDEX 


Baked  potato,  preparation  of,  81 
Baked  tapioca,  preparation  of,  94 
Baking,  39 
Bananas,  ash  constituent  of,  16 

composition  and  fuel  value  of,  144 
Banting's  method  for  obesity,  399,  400 
Barley,  ash  constituent  of,  16 

composition  and  fuel  value  of,  144 
Barley  water,  220 
Base-forming  foods,  129,  424 
Bass,  composition  and  fuel  value  of,  144 
Bath,  infant's,  168 
Beans,  ash  constituent  of,  16 

composition  and  fuel  value  of,  144 
Beef,  ash  constituent  of,  16,  17 

composition  of,  4,  5,  144 

cuts  of,  30 

fuel  value  of,  144 

selection  of,  32 
Beef  broth,  composition  and  fuel  value 
of,  144 

preparation  of,  70,  223 
Beef  juice,  composition  and  fuel  value  of, 
144 

preparation  of,  72,  225 
Beef  marrow,  composition  and  fuel  value 

of,  144 
Beef  soup,  composition  and  fuel  value  of, 

144 
Beef  steak,  preparation  of,  90 
Beer,  ash  constituent  of,  16 
Beets,  ash  constituent  of,  16 
Benedict's  solution,  359 
Benedict's  test  for  sugar  in  urine,  356, 

357 
Beverages,  preparation  of,  63 

selection  of,  29 
Bile,  117 

action  of,  upon  fat,  118 
Biliousness,  379,  388 
Birds,  k  la  bain  mari6,  preparation  of,  86 
Biscuit,  composition  and  fuel  value  of, 

144 
Blackberries,  ash  constituent  of,  16 
Blueberries,  ash  constituent  of,  16 
Bluefish,  composition  and  fuel  value  of, 

144 
Body,  as  an  engine,  109 

ash  of,  108 

bacterial  action  in,  124 

carbohydrates  of,  107 

chemical  composition  pf,  107 

fats  of,  108 

food  requirements  of,  131 
factors  determining,  132 

metabolism  of  tissues  of,  109 

mineral  salts  of,  108 

proteins  of,  107 


Body,  selection  of  food  by,  110 

utilization  of  food  by,  108,  109 

water  of,  108 
Boiling,  39 

Bomb  calorimeter,  46 
Borax,  test  for,  37 
Boric  acid,  test  for,  37 
Bowels,  infant's,  167 
Bran,  composition  and  fuel  value  of,  144 
Bran  biscuits,  preparation  of,  79,  371 

for  constipation,  372 
Bran  cookies,  preparation  of,  79,  260 
Bran  gems,  preparation  of,  78,  259,  260 
Bran  muffins,  preparation  of,  259,  371 
Brandy,  composition  and  fuel  value  of, 

144 
Bread,  ash  constituent  of,  16 

composition  and  fuel  value  of,  144 
Breast  feeding   versus   artificial  feeding, 

203 
Bright's  disease,  see  Nephritis 
Broiled  fish,  preparation  of,  87 
Broiled  oysters,  preparation  of,  88 
Broiled  tomatoes,  preparation  of,  84 
Broiling,  40 
Broths,  preparation  of,  70 

standard,  70 
Brown  betty,  preparation  of,  97 
Bulgarian  buttermilk,  preparation  of,  64 
Butter,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 
Buttermilk,  27,  221 

ash  constituent  of,  16 

Bulgarian,  preparation  of,  64 
Buttermilk  lactone,  preparation  of,  64 
Buttermilk  mixtures,  174 

for  infants,  221 
Butyric  acid,  10 

Cabbage,  ash  constituent  of,  16 
Calciima,  in  infant's  diet,  200 

requirements  in  pregnancy  and  lacta- 
tion, 159 

retention  and  excess,  200 

source  of,  in  food,  6 
Calf's-foot  jelly,  preparation  of,  73 
Calorie  defined,  46 
Calorie  equivalent  in  carbohydrate-free 

meat  and  fish,  349 
Calories,  in  carbohydrates,  48 

in  fats,  48 

in  proteins,  48 
Calorimeter,  46,  47 
Canned  goods,  29 

adulteration  of,  37 
Caramel  custard,  preparation  of,  92 
Carbohydrates,  3 

absorption  of,  119 


INDEX 


433 


Carbohydrates  as  foodstuffs,  3 

calories  in,  48 

composition  of,  7 

enzymes  acting  upon,  114,  115 

excess  of,  in  infant's  diet,  205 

fate  of,  125 

food  equivalent  of,  348 

function  of,  337 

metabolism  of,  125 

of  body,  107 

passage  of,  from  stomach,  122 

regulation  of,  in  formulas,  194 

source  of,  7 
in  foods,  6 

tolerance  of,  in  diabetes,  343    n. 
Carbohydrate-free  diet,  58 
Carbohydrate-free  meat  and  fish,  calorie 

equivalent  of,  349 
Carbon  dioxide,  excretion  of,  298 
Carrots,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 

with  cream  sauce  or  butter,  prepara- 
tion of,  83 
Casoid  flour  and  bean  muffins,  prepara- 
tion of,  372 
Cauliflower,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 
Celery,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 
Cellulose,  9 
Centigrade  scale,  62 
Cereal  diluents  in  infant  feeding,  174 
Cereal  grains,  composition  of,  21 
Champagne  mint  julep,  preparation  of, 

68 
Chase    and    Rose,    nephritic    diet    of, 

308 
Cheese,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 
Cheese  salad,  preparation  of,  370 
Chicken,  k  la  bain  mari6,  preparation  of, 
86 

ash  constituent  of,  17 

baked,  86 

composition  and  fuel  value  of,  146 

roasted,  86 

selection  of,  32 
Chicken  broth,  preparation  of,  70,  223 
Chicken  jelly,  preparation  of,  72 
Children, 

care  of,  in  abnormal  conditions,  191 

digestive  disorders  in,  191,  205 

feeding  of,  183 

in  abnormal  conditions,  191 
Chlorine,  source  of,  in  food,  7 
Chocolate,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 
Chocolate  junket,  preparation  of,  102 


Chyme,  112,  116 

Clam    bouillon,    composition    and    fuel 

value  of,  146 
Clam  broth,  preparation  of,  71,  72 
Cocoa,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 

preparation  of,  70 
Cocoa  junket,  preparation  of,  102 
Cocoanut,  ash  constituent  of,  16 
Cocoanut  biscuits,  374 
Cocoanut  flour,  374 
Coddled  eggs,  39 

preparation  of,  75 
Codfish,  ash  constituent  of,  16 
Coffee,  ash  constituent  of,  16 

adulteration  of,  38 

preparation  of,  70 
Coffee  eggnog,  preparation  of,  69 
Coffee  junket,  preparation  of,  102 
Cold,  effects  of,  on  food,  50 
Coleman's  high  calorie  diet,  for  typhoid 

fever,  262 
Combustion,  heat  of,  47 
Condensed  milk,   composition  and  fuel 
value  of,  146 

for  infants,  187 
Conserve,  preparation  of,  259 
Consomme,  composition  and  fuel  value 

of,  146 
Constipation,  249,  257 

bran  biscuits  for,  372 

dietetic  treatment  in,  249,  250 

diet  for,  381 

diet  formulas  for,  251,  258 

in  infants  and  children,  198,  207 
dietetic  treatment  in,  197 
factors  inducing,  198 
Convalescent  diet,  58 
Cooking,  effects  of,  49 

meats,  89 

substitution  in,  43 

time  table  for,  41 
Corn,  ash  constituent  of,  16 

canned,  38 

composition  and  fuel  value  of,  146 
Corned  beef  with  cabbage,  preparation 

of,  369 
Cornflakes,  composition  and  fuel  value 

of,  146 
Corn  meal,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 
Corn-meal  gruel,  preparation  of,  80 
Cornstarch,  composition  and  fuel  value 

of,  146 
Cottonseed,  composition  of,  22 
Crab,  preparation  of,  88 
Crackers,  ash  constituent  of,  16 

composition  and  fuel  value  of,  146 


434 


INDEX 


Cranberries,  composition  and  fuel  value 
of,  146 

Cream,  ash  constituent  of,  16 
composition  of,  146,  170 
egg  and  vichy,  preparation  of,  69 
fuel  value  of,  146 
of  asparagus,  preparation  of,  74 
of  asparagus  soup,  preparation  of,  74 
of  carrot  soup,  preparation  of,  75 
of  cauliflower,  preparation  of,  368 
of  celery  soup,  preparation  of,  75 
of  pea  soup,  preparation  of,  75 
of  potato,  preparation  of,  74 
of  spinach  soup,  preparation  of,  75 

Cream  sauce  for  cream  soups,  prepara- 
tion of,  73 

Cream  soups,  preparation  of,  368 

Cream  toast,  preparation  of,  77 

Creamed  egg  and  toast,  preparation  of, 
76 

Creamed  potato,  preparation  of,  81 

Creatinin,  126,  128 

Cucumbers,  ash  constituent  of,  16 
composition  and  fuel  value  of,  146 

Currant  ice,  preparation  of,  102 

Currants,  composition  and  fuel  value  of, 
146 

Custard,  preparation  of,  375 
baked,  preparation  of,  92 

Dairy  products,  28 

Dandelion  greens,  ash  constituent  of,  16 

Dates,  ash  constituent  of,  16 

composition  and  fuel  value  of,  148 
Derived  proteins,  13 
Desserts,  preparation  of,  92 
Dextrimaltose,  195,  205 

in  infant  feeding,  173 
Dextrin,  9 
Diabetes,  337 

acetone  bodies  in,  361 

acidosis  in,  338,  345,  361,  424,  428 

alkalies  in,  345 

Allen's  starvation  treatment  in,  338, 
361 

carbohydrate-free  diets  in,   352,   353, 
354,  355 
menus  in,  350 

carbohydrate  tolerance  in,  343 

determination  of  food  tolerance  in,  343 

dietetic  treatment  in,  345 

diets  in,  346,  347 
in  mild  cases,  339 

fast  days  in,  344 

fasting  in,  342 

fat  tolerance  in,  344 

foods  in,  365 

menus  for,  340,  341,  365,  366,  367,  368 


Diabetes,  protein  tolerance  in,  344 

schedule  of  treatment  for,  343 

starvation  treatment  of,  338 

test  diets  in,  339 

urine  in,  301,  337,  356 
Diabetes      muffins,       preparation       of, 

371 
Diabetic  acidosis,  424 
Diabetic  cures,  338 
Diabetic  diet,  58 
Diabetic  flours,  364 
Diabetic  foods,  commercial,  364 
Diacetic  acid  in  urine,  Gerhardt's  test 

for,  360 
Diarrhea,  243,  244,  245 

causes  of,  243 

dietetic  treatment  in,  244,  245 

foods  to  be  avoided  in,  246,  255 

in  infants  and  children,  206,  243 
dietetic  treatment  of,  197 
Diastase  liver,  114 
Diastase  muscle,  114 
Diet,  or  Diets,  and  see  under  the  various 
Diseases 

carbohydrate-free,  58 

convalescent,  58 

emaciation,  59 

fluid,  58 

formulation  of,  44 

house,  58 

light,  58 

liquid,  58 

milk,  58 

mixed,  58 

nephritic,  58,  and  see  Nephritis 

obesity,  59,  and  see  Obesity 

purin-free,  58 

salt-free,  58 

semi-solid,  58 

special,  58 
Digestion,  chemical,  110,  113,  115 

defined,  110 

factors  influencing,  120 

gastric,  115,.  120 

intestinal,  117,  118 

mechanical,  110 

salivary,  115 
Digestive    disturbances   in   infants   and 

children,  191,  205 
Diluents  for  milk,  176 
Diphtheria,  213,  218 

complications  of,  213 

convalescent  diet  in,  213 

dietetic  treatment  in,  213,  219 

gavage  in,  219 

rectal  feeding  in,  213,  219 
Disaccharides,  8 
Dishes,  washing,  35 


INDEX 


435 


Duck,  33 

baked,  preparation  of,  86 

roast,  preparation  of,  86 
Dysentery,   dietetic   treatment  of,   247, 
256 

Ebstein's  method  for  obesity,  401 
Egg,  or  Eggs,  19 

ash  constituent  of,  16 

coddled,  39 

composition  of,  19,  148 

fresh,  33 

fuel  value  of,  148 

method  of  preparation  of,  75 

new  laid,  33 

poached,  preparation  of,  76 

selection  of,  33 

use  of,  in  tuberculosis,  282 
Egg  junket,  preparation  of,  102 
Egg  nests,  preparation  of,  76 
Eggnog,  preparation  of,  66,  68,  69 
Egg  salad,  370 

Eggwhite  and  mint,  preparation  of,  68 
Eiweissmilch,  174,  175 
Emaciation,  409 

allowable  foods  in,  412 

dietetic  treatment  in,  412,  419 

diet  in,  59,  411 

diet  sheets,  413,  414 

in  children,  410 

method  of  increasing  diet  in,  415 

milk  cure  in,  412 

need  for  building  foods  in,  410 

regulating  diet  in,  411 

selection  of  foods  in,  411 
Emulsions,  12 
Enema,  or  Enemas,  malted  milk,  143 

milk  and  starch,  143 

nutrient,  143 

temperature  of,  141 
Energy  output  compared  with  food  in- 
take, 398 

production  of ,  125 
Enteritis,  acute,  244 

dietetic  treatment  in,  244,  245,  246 

food  to  be  avoided  in,  246 
Enteritis,  chronic,  246 

dietetic  treatment  in,  246 
Enterocolitis,  247,  256 

in  infants  and  children,  206 
dietetic  treatment  of,  197 
Enzymes,  113 

acting  on  carbohydrates,  114,  115 
proteins,  114,  115 
purins,  114 

action  of,  113 

amylolytic,  115  ^ 

autolytic,  114 


Enzymes,  classification  of,  115 

coagulating,  115 

deaminizing,  115 

glycolytic,  114 

hydrolytic,  115 

lipolytic,  115 

oxidizing,  115 

proteolytic,  115 

reducing,  115 

sugar-splitting,  115 

table  of,  114 
Erepsin,  114,  117 
Errors  in  diet,  in  infants  and  children, 

191,  204 
Exercise,  influence  of,  on  food  require- 
ments, 135 

Fahrenheit  scale,  62 

Farina,  composition  and  fuel  value  of, 
148 

preparation  of,  80 
Fast  days,  in  treatment  of  diabetes,  344 
Fat,  or  Fats,  3,  10 

absorption  of,  118 

action  of  bile  upon,  118 

as  food  stuffs,  3 

calories  in,  48 

cause  of  gastro-intestinal  disturbances 
in  children,  192 

composition  of,  10 

effect  of  heat  on,  51 

enzymes  acting  on,  114,  115 

excess  of,  and  calcium  retention,  200 
in  diet  of  infants  and  children,  193, 
205 

fate  of,  126 

metabolism  of,  in  acidosis,  423 

of  body,  108 

passage  of,  from  stomach,  121,  122 

phosphorized,  11 

physical  peculiarities  of,  12 

regulation  of,  in  diet,  193  * 

source  of,  10,  11 
in  foods,  6 

tests  for,  12 

tolerance  of,  in  diabetes,  344 

use  of,  in  constipation,  251,  258 

volatile,  12 
Fatty  acids,  type  of,  10 
Fatty    foods,    effect    of,    upon    gastric 

secretion,  121 
Feeding,  by  inunction,  142 

by  mouth,  140 

correct,  evidences  of,  202    - 

forced,  140 

infant-,  see  Infant-feeding 

methods  of,  140 

rectal,  141,  142 


436 


INDEX 


Fehling's  solution,  359 

Fehling's  test  for  sugar  in  urine,  356 

Fermentation,  113 

digestive,  causes  of,  196 

in  stomach,  123 

of  food,   cause  of  infantile  disorders, 
206 
Fermentation  test  for  sugar  in  urine,  358 
Fever,  or  Fevers,  273 

care  of  mouth  in,  276,  278 

convalescent  diet  in,  275,  278 

dietetic  treatment  in,  273,  278 

energy  expenditure  in,  261 

energy  requirements  in,  276 

fluid  diet  in,  274 

nitrogen  equilibrium  in,  278 

of  short  duration,  diet  in,  209 
treatment  of,  273 

sample  menus  for,  275 

schedule  of  feeding  in,  274 

soft  diet  in,  275 

thirst  in,  277,  278 

tissue  waste  in,  273 

typhoid,  see  Typhoid  fever. 
Fibrin  ferment,  115 
Figs,  ash  constituent  of,  16 

composition  and  fuel  value  of,  148 
Fish,  ash  constituent  of,  16 

boiled,  preparation  of,  87 

carbohydrate-free,  calorie  value  of,  349 

selection  of,  33 
Fish  steaks  stuffed  with  oysters,  prepara- 
tion of,  88 
Flavors,  absorption  of,  by  foods,  34 
Floating  island,  preparation  of,  97 
Flour,  composition  and  fuel  value  of,  148 
Flours,  diabetic,  364 
Fluid  diet,  58 

in  fevers,  211 
Foamy  omelet,  preparation  of,  77 
Foamy  sauce,  preparation  of,  96 
Food,  or  Foods,  1,  and  see  Foodstuffs 

absorption  of  odors  and  flavors  by,  34 

acid-forming,  129,  423 

adulteration  of,  36 

antiscorbutic,  201,  208 

approximate  weights  and  measures  of, 
61 

arrangement  of,  in  stomach.  111 

as  fuel,  46,  47,  110 

ash  constituents  of,  15,  16,  17 

base-forming,  129,  424 

behavior  of,  in  metabolism,  128 

carbohydrate  equivalent  of,  348 

care  of,  34 

chemical  composition  of,  7,  53,  54,  55, 
56,  57 

chemical  elements  in,  1 


Food,  or  Foods,  classification  of,  1,  2 

-combinations,  use  of,  129 

contamination  of,  35 

defined,  1 

diabetic,  364,  365 

effect  of  cold  upon,  50 
of  cooking  upon,  49 
of,  upon  secretion  of  urine,  301 

formulas  for  preparation  of,  for  sick,  63 

fuel  value  of,  46,  47,  110 

functions  of,  1 

incomplete,  as  a  source  of  danger,  187 

intake  of,   compared  with  output  of 
energy,  398 

mineral  matter  in,  15 

passage  of,  from  stomach,  112 

preparation  of,  38,  39 
factors  affecting,  49 

relation  of,  to  mother's  milk,  168 

requirements  of  body,  131,  135,  138 
factors  influencing,  132, 134, 138, 139 

Rubner's  fuel  value  of,  48 

salt  content  of,  324,  325,  326 

selection  of,  28 
by  body,  110 

stimulating  peristalsis,  257 

sources  of,  2,  7 

transformation  of,  in  body,  136 
into  fuel,  47 

uses  of,  1,  2,  398 

utilization  of,  in  body,  108,  109 

which  produce  fat,  419 
Food  materials,  1 
Food  poisoning,  36,  426 
Foodstuffs,  fats  as,  3 

organic,  7 
Forced  feeding,  140 
Formaldehyde,  test  for,  37 
Formulas  for  feeding  infants,  177,  181, 
220 

sick  persons,  63 
Fowl,  composition  and  fuel  value  of,  148 
French  dressing,  preparation  of,  91 
Fresh  air,  in  tuberculosis,  283 
Fructose,  8 

Fruit  jellies,  preparation  of,  100,  376 
Fruits,  composition  of,  22 
Frying,  40 

Fuel,  food  as,  46,  47,  110 
Fuel  value  of  formulas,  to  compute,  180 

Galactose,  8 

Gall-bladder,   diet  after   operations  on, 

294,  297 
Gall-stones,  383 

available  foods,  384 

dietetic  treatment  for,  383,  384 

diet  sheets  for,  385,  386 


INDEX 


437 


Gas-forming  foods,  250 
Gastric  cancer,  236,  241 

dietetic  treatment  in,  236,  241 
Gastric  digestion,  115,  120 

hemorrhage,  232 
Gastric  juice,  composition  of,  116 

retardation  of,  121 

stimulation  of,  121 
Gastric  secretion,  effect  of  alkaline  car- 
bonates on,  121 

effect  of  fatty  foods  on,  121 
Gastric  ulcer,  231,  240 

convalescent  diet  in,  234 

dietetic  treatment  in,  232,  233 

instructions  for  nurses  in,  235 

proprietary  foods  in,  241 
Gastritis,  acute,  226,  229,  238 

dietetic  treatment  in,  229,  238 

gastric  juice  in,  227 
Gastritis,  chronic,  226,  230 

dietetic  treatment  in,  227,  231,  239 

gastric  juice  in,  227 
Gastroenterostomy,  diet  after,  297 
Gautier's  dietary,  131 
Gavage,  140 

in  diphtheria,  219 
Gelatine,  composition  and  fuel  value  of, 

148 
Gerhard's    ferric    chloride    reaction    for 

diacetic  acid,  360 
Globulins,  13 
Glucose,  7 
Gluten    bread,    composition    and    fuel 

value  of,  144 
Glycogen,  9 
Glycosuria  in  gout,  393 
Goose,  33 
Gout,  391 

alcohol  in,  392 

allowable  foods  in,  394 

avoidable  foods  in,  395 

dietaries  in,  395 

dietetic  treatment  in,  394,  416 

foods  to  be  condemned  in,  394 

glycosuria  in,  393 

obesity  in,  393 

purin-free  diet  in,  393 
Graham    bread,    composition    and    fuel 

value  of,  144 
Grapefruit,  ash  constituent  of,  16 
Grape  juice,  ash  constituent  of,  16 

composition  and  fuel  value  of,  148 
Grape  juice,  albumenized,  preparation  of, 

67 
Grape-juice  ice,  preparation  of,  101 
Grape-juice  jelly,  preparation  of,  100 
Grapes,  ash  constituent  of,  16 

composition  and  fuel  value  of,  148 


Greens,  composition  and  fuel  value  of, 

148 
Growth,  proteins  producing,  137 
Gruel,  cornmeal,  preparation  of,  80 
Guanase,  114 
Guanin,  127 
Gum  gluten,  composition  and  fuel  value 

of,  148 

Haines's  solution,  359 

Haines's  test  for  sugar  in  iirine,  357 

Halibut,  ash  constituent  of,  16 

composition  and  fuel  value  of,  148 
Halpin's  salt-free  nephritic  diet,  310 
Ham,  composition  and  fuel  value  of,  148 
Hard  sauce,  preparation  of,  97 
Heart  diseases,  dietetic  treatment  in,  331 

modified  Karell  treatment  in,  332 
Heat,  effect  of,  on  fats,  51 
on  foods,  53 
on  protein,  52 
on  starch,  50 

of  combustion,  47 
Hedinger-Schlayer-Mosenthal  diet,  316, 

318 
Heller's  test  for  albumen  in  urine,  303 
Hemoglobin,  14 
Hemoglobins,  13 
Hemorrhages,  gastric,  232 

in  scurvy,  200 
Hickory  nuts,  composition  and  fuel  value 

in,  148 
High  calorie  diet,  in  tuberculosis,  282 

in  typhoid  fever,  261 
Hollandaise  sauce,  preparation  of,  89 
Hominy,  composition  and  fuel  value  of, 

148 
Homogenized  milk,  175 
Honey,  ash  constituent  of,  17 

composition  and  fuel  value  of,  148 
Hormones,  117 
House  diet,  58 

Hyperacidity  in  gastric  ulcer,  232 
Hyperchlorhydria,  228 

lavage  in,  229 
Hypochlorhydria,  227 

dietetic  treatment  in,  228 
Hypoxanthin,  127 

Ice,  apricot,  preparation  of,  101 

Icebox,  care  of,  42 

Ice  creams,  preparation  of,  102,  377 

to  reinforce,  103 
Ices,  in  diabetes,  376 
Indican  in  urine,  test  for,  303 
Infant,  or  Infants, 

bath  for,  168 

bowels  of,  167 


438 


INDEX 


Infant,  or  Infants,  care  of,  in  abnormal 
conditions,  191 

danger  of  incomplete  foods  for,  187 

digestive  disturbances  in,  191,  205 

dietetic  treatment  of  disorders  of,  206 

energy  requirements  of,  165 

enterocolitis  in,  206 

dietetic  treatment  of,  197 

errors  of  diet  in,  191 

feeding,  see  Infant-feeding. 

food  for,  167,  186 

premature,  see  Premature  infants. 

proprietary  foods  for,  186 

quantity  of  milk  needed  for,  165 

weight  of,  167 
Infant-feeding,  166 

alkalies  used  in,  172,  173 

artificial,  172 

breast  versus  artificial,  203 

cereal  diluents  in,  174 

dextrimaltose  in,  173 

formulas  for,  177,  181,  220 

from  10th  to  12th  month,  182 

in  abnormal  conditions,  191 

in  infectious  diseases,  209 

normal,  167 

regularity  in,  167 

rules  and  regulations  for,  170 
Infectious    diseases,    dietetic    treatment 
of,  218 

diet  in,  209 

in  infancy  and  childhood,  feeding  in, 
209,  210,  211 
Intestinal  digestion,  117,  118 
Intestinal  movements,  112,  113 
Intestinal  peristalsis,  112 
Intestinal  secretions,  stimulation  of,  117 
Intestines,  bacterial  action  in,  124 

behavior  of  food  in,  112 

movements  of,  112,  113 

muscular  constriction  in,  116 

secretory  cells  of,  112 
Inunction,  feeding  by,  142 
Invertase,  114 
Iodine,  source  of,  in  food,  7 
Irish  moss  pudding,  preparation  of,  377 
Iron,  source  of,  in  food,  7 

Jellies,  for  diabetics,  375 
preparation  of,  73,  99 
Jell-0,  composition  and  fuel  value  of,  150 
Junket,  preparation  of,  102,  103,  224 

Karell  cure,  in  heart  diseases,  333 

in  nephritis,  310 
Kidneys,  function  of,  298 

functional  tests  of,  315,  316,  318,  319 

in  febrile  conditions,  217 


Kidneys,  in  t3T)hoid  fever,  271 
operations  on,  diet  after,  294,  297 

Koumiss,  27       i 

composition  and  fuel  value  of,  150 

Lactase,  114 

Lactation,  diet  in,  159,  162,  163,  164 
calcium  requirements  in,  164 
phosphorus  requirements  in,  164 
Lactone  buttermilk,  preparation  of,  64 
Lactose,  8 

composition  and  fuel  value  of,  150 
in  infant  feeding,  173 
Lady  fingers,  composition  and  fuel  value 

of,  150 
Lamb,  ash  constituent  of,  17 

cuts  of,  31 
Lamb  chops,  composition  and  fuel  value 
of,  150 
preparation  of,  90 
Lard,   composition  and    fuel   value  of, 

105 
Laxative  foods,  use  of,  for  infants  and 

children,  198 
Lecithin,  11 
Lecithins,  11 
Lemonade,  albumenized,  preparation  of, 

66 
Lemon  ice,  preparation  of,  100,  376 
Lemon  ice  cream,  preparation  of,  102 
Lemon  jelly,  preparation  of,  99,  375 
Lemon  juice,  ash  constituent  of,  17 

composition  and  fuel  value  of,  150 
Lentils,  ash  constituent  of,  17 

composition  and  fuel  value  of,  150 
Lettuce,  ash  constituent  of,  17 

composition  and  fuel  value  of,  150 
Light  diet,  58 
Linen,"  44 
Lipase,  114 
Liquid  diet,  58 
Liquid  peptonoids,  composition  and  fuel 

value  of,  150 
Lister  cream  puff,  preparation  of,  375 
Lister  flour  and  bran  muffins  or  biscuits, 

preparation  of,  373 
Lister  muffins,  preparation  of,  372 
Liver,  cirrhosis  of,  382,  389 
avoidable  foods  for,  382 
dietetic  treatment  in,  382 
diseases  of,  379 

convalescence,  diet  in,  380 
dietetic  treatment  in,  380 
functions  of,  387 

operations  on,  diet  after,  294,  297 
Lobster,  composition  and  fuel  value  of, 
150 
preparation  of,  88 


INDEX 


439 


Macaroni,  composition  and  fuel  value  of, 

150 
Mackerel,  composition  and  fuel  value  of, 

150 
Magnesium,  source  of,  in  foods,  7 
Malnutrition,  202 
Maltase,  114 
Malted   foods,  for  infant  feeding,   173, 

187 
Malted  milk,  composition  and  fuel  value 
of,  150 

preparation  of,  67 
Malted  milk  chocolate,  preparation  of,  67 
Malted  milk  cocoa,  preparation  of,  67 
Malted  milk  eggnog,  preparation  of,  68 
Malted  milk  enema,  143 
Malt  soup,  preparation  of,  222 
Malt  sugar  in  infant  feeding,  173,  174 
Maltose,  8 
Mastication,  111 
Matzoon,  27 

Mayonnaise,  preparation  of,  91 
Measles,  216,  220 

dietetic  treatment  in,  217,  220 
Meat,  ash  constituent  of,  17 

carbohydrate-free,    calorie   equivalent 
of,  349 

composition  of,  20 

cooking  of,  89 

cuts  of,  30 

in  pregnancy,  164 

quality  of,  31 

selection  of,  30 
Metabolism,  behavior  of  food  in,  128 

definition  of,  125 

factors  affecting,  130 

in  febrile  conditions,  217 

in  normal  and   abnormal  conditions, 
139 

of  body  tissues,  109,  126 

of  carbohydrates,  125 

of  proteins,  126,  128 

processes  of,  110 

rate  of,  in  typhoid  fever,  269 
Metric  system,  59 
Milk,  adulteration  of,  26 

albumenized,  preparation  of,  63 

and  ginger  ale,  preparation  of,  67 

and  sarsaparilla,  preparation  of,  67 

and  starch  enemas,  143 

application  of  heat  to,  24 

ash  constituent  of,  17 

breast  versus  cows',  169 

butter-,  see  Buttermilk 

care  of,  27 

certified,  28 

composition  of,  29 

composition  of,  22,  150,  170 


Milk,  condensed,  see  Condensed  milk 
composition  and  fuel  value  of,  146 

diet,  58 

fats  in,  measuring  according  to,  176 

formulas,  222,  223 

fuel  value  of,  150 

homogenized,  175 

method  of  administering  to  premature 
infant,  186 

modification  of,  technique  of,  175 

modified,  diluents  for,  176 

pasteurization  of,  25,  176 

peptonized,  preparation  of,  63 

quantity  of,  needed  for  infant,  165 

secretion  of,  factors  regarding,  164 
factors  retarding,  163 
factors  stimulating,  165 

selection  of,  27 

skimmed,  27 

sterilization  of,  25 

sugar-free,  364 

use  of,  in  nephritis,  307 
in  pneumonia,  286 
in  tuberculosis,  282 
Milk  punch,  preparation  of,  65 
Milk  shake,  preparation  of  albumenized, 

65 
Milk  toast,  preparation  of,  78 
Mineral  oils,  use  of,  in  constipation,  258 
Mineral  salts,  absorption  of,  120 

of  body,  108 

sources  of,  in  food,  6 
Mixed  diet,  58 
Molasses,  ash  constituent  of,  17 

composition  and  fuel  value  of,  150 
Monosaccharides,  7 
Morse  and  Talbot's  method  of  infant 

feeding,  179 
Mother's  milk,  fuel  value  of,  165 

making  of,  165 
Mouth,  care  of,  in  typhoid,  271 
Muffins,  diabetes,  preparation  of,  371 
Muskmelons,      composition      and     fuel 

value  of,  150 
Mutton  broth,  preparation  of,  70,  223 
Mutton  chops,  preparation  of,  90 
Mutton,  cuts  of,  31 

Nephritis,  305 

acute,  305 

adjusting  diet  in,  307 

adjusting  fluids  in,  307 

advisable  foods  in,  312 

available  foods  in,  308 

Chase  and  Rose's  diet  in,  308 

chronic,  305,  314 

dietetic  treatment  in,  314 
functional  tests  in,  315,  316 


440 


INDEX 


Nephritis,  chronic,  protein  diet  in,  314 
chronic  interstitial,  319 
dietetic  treatment  in,  320 
limiting  fluid  in,  320 
limiting  nitrogen  in,  321 
selection  and  preparation  of  food  in, 
321 
convalescent  diet  in,  312 
diet  in,  58,  308,  313,  323 
effects  of,  305 
elimination  of  salt  in,  309 
Halpin's  diet  in,  310 
in  scarlet  fever,  212,  218 
Karell  cure  in,  310 
limiting  the  amount  of  food  in,  310 
milk  cure  in,  307 
preparation  of  food  in,  312 
proteins  in,  311 
salt-poor  diets  for,  309 
selection  of  foods  in,  312 
thirst  in,  311 
Widal's  diet  in,  310 
Neufchfttel  cheese  salad,  preparation  of, 

370 
Nitrogen,  retention  of,  in  infancy,  133 
Nitrogenous   substances,  oxidation  and 

excretion  of,  299 
Noodles,  composition  and  fuel  value  of, 

150 
Normal  saline  solution,  143 
Nucleoproteins,  13,  14 
Nursing  infant,   food   requirements   of, 

162 
Nursing  mother,  diet  of,  163 

habits  of,  168 
Nut  charlotte,  preparation  of,  96,  378 
Nutrient  enemas,  143 
Nutrition,  disturbances  of,  in  pregnancy, 

159 
Nutritional    disorders    in    infants    and 
children,  205 

Oatmeal,  ash  constituent  of,  17 

composition  and  fuel  value  of,  150 
Oatmeal  cookies,  preparation  of,  260 
Oats,  composition  and  fuel  value  of,  150 
Oat  water,  preparation  of,  221 
Obese  women,  Rose's  reducing  diet  for, 

404 
Obesity,  397 

allowable  foods  in,  402 

amount  of  food  to  be  taken  in,  403 

Banting's  method  in,  399,  400 

cures  for,  397,  399 

dietetic  treatment  of,  402,  417 

diets  for,  59,  399 

Ebstein's  method  in,  401 

exercise  in,  399 


Obesity  in  gout,  393,  394 

limiting  fluids  in,  399 

massage  in,  407 

menus  for,  407,  408,  409 

Oertel's  method  in,  400 

Proudfit's  menu  for,  402,  405,  406 
Odors,  absorption  of  by  foods,  34 
Oertel's  method  in  obesity,  400 
Oleic  acid,  11 
Olein,  11 
Olive  oil,  composition  and  fuel  value  of, 

150 
Olives,  composition  of,  22,  150 

fuel  value  of,  150 
Onions,  ash  constituent  of,  17 

composition  and  fuel  value  of,  150 
Operations,    dietetic    treatment    before 

and  after,  289  et  seq. 
Orangeade,  preparation  of,  66 
Orange    charlotte,    preparation    of,   98, 

378 
Orange  ice,  preparation  of,  101,  377 
Orange  jelly,  preparation  of,  99,  376 
Orange  juice,  ash  constituent  of,  17 

composition  and  fuel  value  of,  152 

for  infants,  182 

in  scurvy,  208 
Orange  rice  custard,  preparation  of,  95 
Orange  tapioca,  preparation  of,  94 
Oranges,  ash  constituent  of,  17 

composition  and  fuel  value  of,  150 
Osmosis,  process  of,  in  body,  129 
Over-dilution  of  infant's  food,  troubles 

due  to,  192 
Over-feeding  of  infants  and  children,  204 
Oxidases,  114,  115 
Oyster  broth,  preparation  of,  71 
Oyster  soup,  preparation  of,  75 
Oysters,  composition  and  fuel  value  of, 
152 

Palmitic  acid,  10 

Panopepton,  and  liquid  peptonoids  egg- 
nog,  preparation  of,  69 

composition  and  fuel  value  of,  152 
Parsley  butter,  preparation  of,  370 
Parsnips,  ash  constituent  of,  17 

composition  and  fuel  value  of,  152 
Pastem-ization,  25,  176 
Peaches,  ash  constituent  of,  17 

composition  and  fuel  value  of,  152 
Peanut    butter,    composition    and    fuel 

value  of,  152 
Peanuts,  ash  constituent  of,  17 

composition  of,  22,  152 

fuel  value  of,  152 
Pears,  ash  constituent  of,  17 

composition  and  fuel  value  of,  152 


INDEX 


441 


Peas,  ash  constituent  of,  17 

canned,  37 

composition  and  fuel  value  of,  152 

preparation  of,  82 
Pecans,  composition  and  fuel  value  of, 

152 
Pellagra,  dietetic  treatment  in,  425,  428 
Pepsin,  114,  116 
Peptones,  13 

Peptonized  milk,  preparation  of,  63 
Peptonoids,   dry,   composition  and  fuel 
value  of,  148 

liquid,  composition  and  fuel  value  of, 
150 
Percentage  calculations,  61 
Peristalsis,  112 

food  stimulating,  257 
Phosphoproteins,  13,  14 
Phosphorized  fats,  11 
Phosphorus  requirements  in  pregnancy 

and  lactation,  159 
Pineapple,  ash  constituent  of,  17 

composition  and  fuel  value  of,  152 
Pineappleade,  preparation  of,  69 
Playf air's  dietary,  131 
Pneumonia,  284,  288 

convalescent  diet  in,  285 

dietetic  treatment  in,  284,  288 
Pneumonia  diet  schedules,  284,  285 
Poached  eggs,  preparation  of,  76 
Poaching,  40 
Poisoning,  food,  36,  426 
Polysaccharides,  8 
Pork,  ash  constituent  of,  17 

in  diet,  31 
Port  wine,  composition  and  fuel  value  of, 

152 
Postoperative  feeding,  292,  293,  296 
Potassium,  sources  of,  in  food,  7 
Potatoes,  ash  constituent  of,  17 

baked,  81 

composition  and  fuel  value  of,  152 

stuffed  with  meat,  preparation  of,  82 
Pregnancy,  albuminuria  of,  diet  in,  164 

diet  in,  159,  160,  161,  163,  164 

nutritional  disturbances  in,  159 
Premature  infants,  dilution  of  food  for, 
185 

energy  requirements  of,  185 

feeding  of,  184,  185 
Preoperative    diet,    289,    290,   291,   295, 

296 
Proprietary  foods,  use  of,  for  infants,  186 
Proteins,  3 

absorption  of,  119 

animal,  4 

as  foodstuffs,  3 

as  protection  against  cold,  138 


Proteins,  calories  in,  48 

complete,  13,  137 

derived,  13 

effect  of  heat  on,  52 

enzymes  acting  on,  114,  115 

excess   of,  in   infants'    and   children's 
food,  194,  205 

in  body,  107 

in  nephritis,  311 

needs  of  body,  137 

passage  of,  from  stomach,  122 

producing  growth,  137 

sources  of,  5,  12 

tolerance  of,  in  diabetes,  344 

vegetable,  4 
Proteoses,  13 

Proudfit's  menu  for  obesity,  402 
Proudfit's  reducing  diet  for  obesity,  405, 

406 
Prune  fig  whip,  preparation  of,  98 
Prune  jelly,  preparation  of,  258 
Prune  pulp,  preparation  of,  258 
Prunes  and  figs,  preparation  of,  259 
Prunes,  composition  and  fuel  value  of, 
152 

preparation  of,  224,  258 
Prune  whip,  preparation  of,  98 
Ptomaines,  36 

poisoning  by,  421 

dietetic  treatment  for,  422 
Ptyalin,  114 

Punch,  milk,  preparation  of,  65 
Pm-in-bearing   foods   as   source   of   uric 

acid,  392 
Purin  bodies,  126,  127 
Purin-free  diet,  58 

in  gout,  393 
Purins,  enzymes,  acting  upon,  114 

Quail,  composition  and  fuel  value  of,  152 
preparation  of,  33 
to  boil,  85 

Raisins,  composition  and  fvfel  value  of, 

152 
Raspberries,  composition  and  fuel  value 

of,  152 
Raspberry  ice,  preparation  of,  102 
Rectal  feeding,  141,  142,  292 
Reductases,  115 
Relapses  in  disease  due  to  errors  of  diet, 

203 
Rennin,  115,  116 
Rest  in  tuberculosis,  283 
Restriction  of  food  in  infectious  diseases, 

209 
Rhubarb,  ash  constituent  of,  17 
composition  and  fuel  value  of,  152 


442 


INDEX 


Rice,  ash  constituent  of,  17 

composition  and  fuel  value  of,  152 
preparation  of,  80,  81 

Rice  custard,  preparation  of,  95 

Rickets,  199 

dietetic  treatment  of,  199,  207 

Roasting,  39 

Rose's  reducing  diet  for  obese  women, 
404 

Rubner's  fuel  value  of  foods,  48 

Rum,  composition  and  fuel  value  of,  152 

Salads,  preparation  of,  90 

egg,  preparation  of,  370 
Saline  solution,  normal,  143 
Saliva,  115 

Salivary  digestion,  115 
Salmon,  composition  and  fuel  value  of, 

152 
Salt,  elimination  of,  in  nephritis,  309 
Salt  content  of  foods,  324,  325,  326 
Salt  foods,  use  of,  250 
Salt-free  diet,  58 
Saltines,  composition  and  fuel  value  of, 

152 
Salts,  ammonium,  126 

mineral,  of  body,  108 
absorption  of,  120 
Salt-poor  diets  in  nephritis,  309 
Sardines,  composition  and  fuel  value  of, 

152 
Sauce  for  puddings,  preparation  of,  96 
Sauteing,  40 

Scalloped  potatoes,  preparation  of,  82 
Scarlet  fever,  211,  218 

convalescent  treatment  in,  212 

dietetic  treatment  in,  211,  218 

nephritis  in,  212,  218 
Scurvy,  200 

errors  of  diet  in,  207 

hemorrhages  in,  200 

in  breast-fed  babies,  201 

lack  of  vitamines  in,  201 

treatmeiA  of,  208 
Secretin,  117 
Semi-solid  diet,  58 

Shad,  composition  and  fuel  value  of,  154 
Shell  fish,  selection  of,  33 
Sherry  wine,  composition  and  fuel  value 

of,  154 
Silver,  44 
Simmering,  39 

Skimmed  milk,  composition  of,  170 
Skin,  in  infectious  diseases,  218 
Sleep,  in  tuberculosis,  283 
Snowballs,  preparation  of,  93 
Snow  pudding,  preparation  of,  98,  375 
Soap  stools,  205 


Sodium,  sources  of,  in  food,  7 

Soft-cooked  eggs,  76 

Soft  custard,  preparation  of,  93 

Soya  meal  and  bran  muflfins,  preparation 

of,  373 
Spanish  cream,  preparation  of,  374 
Special  diets,  58 
Spinach,  ash  constituent  of,  17 

composition  and  fuel  value  of,  154 

preparation  of,  83 
Spinach  soup,  preparation  of,  369 
Sponge  pudding,  preparation  of,  99 
Squab,  composition  and  fuel  value  of,  154 

preparation  of,  33 

to  boil,  85 
Squash,  ash  constituent  of,  17 

composition  and  fuel  value  of,  154 
Squirrel,  33 
Starch,  9 

effect  of  heat  on,  50 

excess  of,  in  food  formulas,  195. 
in  infants'  and  children's  food,  206 
Starvation,  in  treatment  of  diabetes,  338, 
361 
of  infantile  diarrhea,  206 
Steaming,  39 
Steapsin,  114 
Stearic  acid,  11 
Stearin,  11 
Sterilization,  25 
Stewed  tomatoes  on  toast,  preparation  of, 

84 
Stomach,  see  Gastric 

arrangement  of  food  in.  111 

fermentation  in,  123 

movements  of.  111 

passage  of  food  from,  112 

secretory  cells  of,  112 
Stools  of  infants  and  children,  205 
Strawberries,  ash  constituent  of,  17 

composition  and  fuel  value  of,  154 
Strawberry  ice,  preparation  of,  101 
String   beans,    preparation    of,    83;    see 

Beans 
Substitution  in  cooking,  43 
Succus  entericus,  117 
Sucrase,  114 
Sucrose,  8 

Suet,  composition  and  fuel  value  of,  154 
Sugar,  adjusting  of,  in  food  formulas,  195 

composition  and  fuel  value  of,  154 

in  infant  feeding,  173 

in  urine,  in  diabetes,  344 
tests  for,  356,  357,  358 

manufacture  of,  from  other  foods,  337 
in  body,  361 
Sugar-free  milk,  364 
Sugar-splitting  enzymes,  115 


INDEX 


443 


Sulphur,  source  of,  in  food,  7 
Sunshine  cake,  preparation  of,  104 
Sweetbreads,  composition  and  fuel  value 
of,  154 
preparation  of,  87 
Syrups,  selection  of,  29 

Tapioca,  composition  and  fuel  value  of, 

154 
Tapioca  custard,  preparation  of,  95 
Tapioca  pudding,  preparation  of,  94 
Test  meals,  230 
Thermometry,  62 
Thirst,  in  nephritis,  311 

in  typhoid  fever,  271 
Thrombase,  115 
Thrombin,  115 
Time  table  for  cooking,  41 
Tissue  waste  in  fevers,  273 
Toast,  cream,  preparation  of,  77 

milk,  preparation  of,  78 
Tomato,  ash  constituent  of,  17 

broiled,  84 

composition  and  fuel  value  of,  154 

stewed,  on  toast,  preparation  of,  84 

stuffed  with  rice,  preparation  of,  84 
Tonsillitis,    dietetic    treatment   of,    286, 

288 
Tomato  aspic,  preparation  of,  371 
Tomato  bisque,  preparation  of,  368 
Tomato  jelly,  preparation  of,  73 
Top  milk,  composition  of,  171 
Toxins,  elimination  of,  298 
Tray,  44 

arranging,  45 
Trout,  composition  and  fuel  value  of,  154 
Trypsin,  114,  117 
Tuberculosis,  279,  283,  287 

dietetic  treatment  in,  279,  280,  287 

high  calorie  diet  in,  282 

reenforcing  the  diet  in,  283 

schedule  of  diets  in,  280 
Tuna  fish  s^lad,  preparation  of,  370 
Turkey,  baked,  86 

composition  and  fuel  value  of,  154 

roasted,  86 

selection  of,  32 
Turnips,  ash  constituent  of,  17 

composition  and  fuel  value  of,  154 
Turnip  tops,  ash  constituent  of,  17 
Typhoid  fever,  261 

absorption  of  food  in,  263,  270 

acidosis  in,  271 

advantage  of  newer  treatment  in,  267, 
271 

care  of  mouth  in,  271 

Coleman's  high  calorie  diet  in,   261, 
262,  266,  264,  270 


Typhoid  fever,  energy  expenditures  in, 
261 
requirements  in,  262 
hemorrhage  in,  269,  270 
high  calorie  diet  in,  261,  262,  264,  266, 

270 
increasing  diet  in,  263,  272 
liquid  diet  in,  265 
milk  diet  in,  263,  269,  271,  272 
Presbyterian  Hospital  diet  list  for,  265 
rate  of  metabolism  in,  269 
refinforcing  diet  in,  272 
semi-solid  diet  in,  266 
soft  diet  in,  266 
third  diet  in,  262 
thirst  in,  271 
varying  diet  in,  264 

Under-balanced    diet    in    infants    and 

children,  204 
Under-dilution  of  infants'  food,  troubles 

due  to,  192 
Under-feeding  in  infants  and  children, 

204 
Utensils,  care  of,  34 
Urea,  126 

and  salt  test,  319 
Uremia,    development    of,     in     chronic 

nephritis,  321 
Uric  acid,  299 

control  of  output  of,  128 

elimination  of,  391 

formation  of,  127 

source  of,  391 
Urinalysis,  298 
Urine,  acetone  in,  test  for,  360 

albumin  in,  tests  for,  302 

analysis  of,  298,  299 

collection  of,  300,  304,  363 

diacetic  acid  in,  test  for,  360 

diseases  in  which  it  is  diminished,  300 

effect  of  food  upon,  301 

examination  of,  in  diabetes,  362,  363 

in  diabetes,  301,  337,  356 

preserving,  304 

sugar  in,  tests  for,  356,  357,  358 


Vanilla  ice  cream,  preparation  of, 
Veal,  32 

•ash  constituent  of,  17 

cuts  of,  31 
Veal  broth,  preparation  of,  70 
Veal  cutlets,  preparation  of,  89 
Vegetable  proteins,  4 
Vegetables,  composition  of,  22 

for  diabetics,  369 

preparation  of,  81 

selection  of,  29 


102 


444 


INDEX 


Vitamines,  17 

lack  of,  in  scurvy,  201,  208 
Voit's  dietary,  131 
Volatile  oil,  11 

Walnuts,  composition  and  fuel  value  of, 

154 
Water,  absorption  of,  120 

administration  of,  to  infants,  181 

as  a  fat  maker,  398 

as  a  stimulus  to  gastric  secretion,  233 

excretion  of,  298 

in  body,  108 

in  food,  15 
Water  ices,  preparation  of,  100,  101 
Weights  and  measures,  approximate,  61 

household,  60 

metric,  59 
Weight  of  body,  gain  in,  133 

influence  of,  on  food  requirements,  139 
Wet  nurses,  189 
Wheat,  ash  constituent  of,  17 

composition  and  fuel  value  of,  154 


Whey,  27 

composition  of,  23,  154 

contraindicated  in  some  fevers  of  in- 
fancy, 210 

fuel  value  of,  154 

preparation  of,  220 
Whey  mixtures,  for  premature  infants, 

186 
Whooping  cough,  214,  219 

dietetic  treatment  of,  214,  215,  219 

stimulation  in,  215,  220 
Widal's  diet  in  nephritis,  310 
Wine,  ash  constituent  of,  17 
Wine  jelly,  preparation  of,  100,  376 
Wine  panade,  preparation  of,  78 

Xanthin,  127 

Zoolac,  27 

Zwieback,  composition  and  fuel  value  of, 

154 
Zymase,  115 


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contribution,  indeed,  to  the  literature  of  nursing  and  service." 

This  work  is  the  only  one  covering  exactly  this  field  and 
the  new  developments  in  public  health  nursing.  Some  of  its 
most  important  chapters  are  on  "  The  History  of  the  PubHc 
Health  Nursing  Movement  "  ;  "  Modern  Problems  "  ;  "  Duties 
of  the  Superintendents  of  Nurses  and  of  the  Staff  Nurses  "  ; 
"  How  to  Organize  a  Visiting  Nurse  Association  " ;  "  The 
Board  of  Managers";  "The  Staff  Nyrse  " ;  "Methods  of 
Organization,  -Administration,  etc."  There  are,  in  addition, 
chapters  covering  the  special  branches  of  public  health  nursing. 


THE  MACMILLAN   COMPANY 

Publishers  64-66  Fifth  Avenue  New  York 


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UNIVERSITY  OF  CAUFORNIA  UBRARY 


